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PUBLIC  HEALTH  AND  INSURANCE: 


AMERICAN  ADDRESSES 


BY 


SIR  ARTHUR  NEWSHOLME,  K.C.B.,M.D.,  F.R.C.P. 

LECTURER  ON  PUBLIC  HEALTH  ADMINISTRATION  AT  THE  SCHOOL  OF  HYGIENE  AND 
PUBLIC  HEALTH,  JOHNS  HOPKINS  UNIVERSITY,  BALTIMORE,  MARYLAND;  LATE 
PRINCIPAL    MEDICAL  OFFICER    OF    THE    LOCAL    GOVERNMENT  BOARD,  ENG- 
LAND ;    PRESIDENT    OF  THE  SOCIETY  OF    MEDICAL  OFFICERS  OF  HEALTH 
AND  OF  THE  EPIDEMIOLOGICAL  SOCIETY;  EXAMINER  IN  PUBLIC  HEALTH 
TO  THE  UNIVERSITY  OF  CAMBRIDGE,  IN    PREVENTIVE    MEDICINE    TO 
THE  UNIVERSITY  OF    OXFORD,  AND    IN    STATE    MEDICINE  TO  THE 
UNIVERSITY  OF  LONDON,  MEMBER    OF  THE   GENERAL  MEDICAL 
COUNCIL,  OF  THE  COUNCIL  OF  THE  IMPERIAL  CANCER 
RESEARCH  FUND,  ETC. 


BALTIMORE 

THE  JOHNS  HOPKINS  PRESS 

1920 


i  -  4  --;  -4 

_»V     -X       -A     .-.'     *./      » 


Copyright,  1920 
By  THE  JOHNS  HOPKINS  PRESS 


PRESS  OF 

THE  NEW  ERA  PRINTING  COMPANY 
LANCASTLR    PA. 


DEDICATED  BY  THE  AUTHOR 
(WITHOUT  PERMISSION) 

TO  THE 

RIGHT  HONOURABLE  JOHN  BURNS 
A  LEADER  IN  PUBLIC  HEALTH  ; 

WHO  IN  PARTICULAR  MADE  THE  PUBLIC  REALISE  THE 
IMPORTANCE  OF  CONCENTRATING  ON  THE 

MOTHER  AND  HER  CHILD 


PREFACE 

After  more  than  three  decades  of  work  in  preventive 
medicine  and  public  health,  the  opportunity  has  arisen 
in  connection  with  a  year's  visit  to  America,  to  take  a 
panoramic  view  of  public  health  in  England,  of  the 
progress  which  has  been  secured,  of  the  factors  which 
have  impeded  progress,  and  of  the  pressing  desiderata 
for  more  efficient  future  action. 

During  my  stay  in  America  I  have  had  the  privilege 
of  addressing  public  audiences  in  every  part,  from  New 
Orleans  to  Toronto,  and  from  New  York  and  Boston 
to  San  Francisco  and  Seattle ;  as  well  as  more  special 
audiences  at  Johns  Hopkins  University,  at  Saranac  and 
at  Harvard,  California,  Washington,  and  Yale  Uni- 
versities ;  and  at  the  request  of  many  friends  some  of 
the  addresses  given  to  these  audiences  are  now  pub- 
lished in  volume  form.  These  addresses  briefly  out- 
line some  of  the  lessons  of  long  experience,  and 
although  the  conditions  under  which  they  were  de- 
livered rendered  complete  exposition  impracticable, 
there  are,  I  think,  advantages  in  not  overloading  the 
presentation  for  public  consideration  of  a  many-sided 
subject. 

It  will  be  noted  that  the  same  problem  may  be  men- 


Vi  PREFACE 

tioned  in  several  addresses,  though  usually  from  a  dif- 
ferent angle.  The  entire  avoidance  of  repetition  would 
have  necessitated  the  abandonment  of  the  lecture 
form,  and  would,  I  believe,  have  diminished  the  utility 
of  the  volume.  The  table  of  contents  and  index  ren- 
der cross-reference  easy. 

Those  wishing  to  ascertain  fuller  details  on  most  of 
the  problems  discussed  in  the  present  volume  may  re- 
fer, I  think  with  advantage,  to  my  annual  reports  as 
Medical  Officer  of  the  Local  Government  Board,  Eng- 
land, and  to  my  four  special  reports  on  Maternal  and 
Child  Mortality,  which  also  were  issued  as  English 
Government  publications. 

British  experience  is  only  partially  applicable  in  the 
United  States,  the  almost  complete  Home  Rule  in  each 
State  creating  a  new  and  interesting  problem  in  effi- 
cient national  public  health  administration.  Never- 
theless a  review  of  events  in  Great  Britain  cannot  fail 
to  be  useful  in  America,  which  is  faced  with  similar 
problems.  The  main  lines  of  public  health  administra- 
tion in  Great  Britain  have  proved  their  value  by  their 
success.  There  has  been  local  independence  with  a 
minimum  of  central  control,  and  the  people's  repre- 
sentatives in  every  area  have  been  made  to  realize  their 
commercial  responsibility.  The  mistakes  made  in  per- 
mitting the  multiplication  of  small  and  inefficient 
public  health  authorities,  in  allowing  official  medical 


PREFACE  Vii 

work  to  be  divided  respectively  between  different  local 
and  central  authorities,  in  sanctioning  the  creation  of 
ad  hoc  authorities  for  special  work,  in  associating  state 
medicine  with  monetary  insurance  against  sickness,  and 
in  not  securing  that  insurance  shall  directly  assist  the 
prevention  of  sickness,  have  been  largely  the  mistakes 
of  politicians  and  of  central  authorities.  These  mis- 
takes involve  the  retracing  of  steps  and  the  undoing  of 
the  mischief  resulting  from  ill-advised  action.  In 
view  of  these  conflicting  events,  the  marvellous 
achievements  secured  by  public  health  authorities  are 
the  more  noteworthy. 

In  every  American  city  visited  by  me  I  have  been 
struck  with  the  earnest  desire  of  voluntary  and  official 
public  health  and  social  workers  to  profit  by  English 
experience,  to  adopt  what  is  good,  to  secure  the  aboli- 
tion of  the  short  tenure  of  office  of  competent  officers 
under  the  present  political  system,  and  to  introduce 
civil  service  conditions  for  them.  There  is  in  many 
respects  a  close  parallelism  between  the  course  of 
public  health  on  both  sides  of  the  Atlantic;  in  some 
cities  the  English  hygienist  has  much  to  learn  in  re- 
spect of  advanced  and  original  work;  and  in  other 
American  cities  in  which  "political  pull"  continues, 
there  is  evidence  of  the  development  of  a  wider  interest 
and  a  more  general  sense  of  communal  responsibility ; 
a  deeper  trend  of  thought  which  will  make  for  steadily 


yiii  PREFACE 

increasing  efficiency  in  public  health  work.  As  this 
volume  discusses  public  health  problems  especially 
from  a  social  viewpoint,  it  is  my  earnest  hope  that  it 
may  be  useful  in  this  direction. 

ARTHUR  NEWSHOLME 

SCHOOL  OF  HYGIENE  AND  AND 

PUBLIC  HEALTH,  ATHENAEUM  CLUB, 
JOHNS  HOPKINS  UNIVERSITY,  LONDON, 

BALTIMORE,  May,  1920 


CONTENTS 


LECTURE  I 

PUBLIC  HEALTH  PROGRESS  IN  ENGLAND  DURING 
THE  LAST  FIFTY  YEARS 1-41 

Parallelism  of  Events  in  Old  and  New  England. 

The  Utilization  of  Lay  Workers  in  Public  Health  Work. 

The  Influence  of  Urbanization  and  Industrialism. 

Laissez  faire  Economic  Teaching. 

Man  and  his  Environment. 

Dirt  and  Disease. 

Cholera,  Typhoid  Fever,  Typhus  Fever. 
Summary  of  Results  in  Life-Saving. 
Specific  Causation  of  Disease. 

Importance  and  Present  Limitations  of  Epidemiology. 
The  Importance  of  Vital  Statistics. 

Conditions  of  Medical  Practice  Bearing  on  Public  Health. 
Poor-law  versus  Public  Health. 
Insurance  versus  Public  Health. 
A  National  Medical  Service. 
Hospitals  Important  Housing  Auxiliaries. 
The  Need  to  Avoid  Complacency. 

LECTURE  II 

HISTORICAL  DEVELOPMENT  OF  PUBLIC  HEALTH 
POLICY  IN  ENGLAND  42-70 

Town-Dwelling  and  Health  Problems. 
The  Scope  of  Public  Health  Work. 

ix 


X  CONTENTS 

Reform  in  the  Control  of  Poverty. 

Reform  in  Industry. 

Public  Health  Reform. 

Education  Authorities  and  Health. 

The  Ad  Hoc  Vice. 

Principles  of  Local  Government. 

The  Training  and  Tenure  of  Office  of  Medical  Officers  of 

Health. 

The  National  Insurance  Act  and  Public  Health. 
Provision  for  Sickness. 
General  Summary. 

LECTURE  III 
THE  INCREASING  SOCIALIZATION  OF  MEDICINE.  71-102 

An  Altruistic  Profession. 

The  Past  Achievements  of  Medicine. 

The  Ever-increasing  Importance  of  Hospitals. 

Hospitals  and  Housing. 

The  Continuing  Mass  of  Preventible  Disease. 
The  Present  Extent  of  Socialization  of  Medicine. 
Destitution  and)  Sickness. 
Insurance  and  Sickness. 
The  Needs  of  the  Future. 

LECTURE  IV 

THE  MEDICAL  ASPECTS  OF  INSURANCE  AGAINST 
SICKNESS   103-1 19 

Criteria  of  Value  of  Insurance. 

British  System  of  Insurance. 

Limitations  and  Evils  of  the  "  Medical  Benefit." 

Need  for  further  State  Treatment  of  Disease. 


CONTENTS  XI 

Prevention  of  Poverty  by  the  Application  of  Medical  Science. 
State  Medicine  must  be  Preventive  throughout. 
Conditions  of  an  Efficient  Medical  Service. 

LECTURE  V 

SOME   PROBLEMS  OF  PREVENTIVE   MEDICINE  OF 
THE  IMMEDIATE  FUTURE 120-143 

The  Incidental  Gains  from  War. 

Its  Sacrificial  Work. 

The  Comradeship  of  All  Idealists. 

Women's  Work. 

The  Restriction  of  Alcoholism. 

The  Change  from  Empirical  to  Scientific  Methods. 
The  Still  Uncontrollable  Diseases. 

Influenza  and  Measles  as  Types. 
The  Possibility  of  Modified  Training  of  Nurses. 
The  Need  for  a  More  Complete  Program  in  Tuberculosis. 
The  Possibilities  of  Control  of  Venereal  Diseases. 
The  More  Complete  Protection  of  Maternity  and  Childhood. 
The  Abolition  of  Poverty  Tests  in  Medical  Assistance. 
Lack  of  Equality  of  Service,  not  Ignorance,  the  Chief  Evil. 
The  Continuing  Value  of  Voluntary  Workers. 

LECTURE  VI 

THE  INTER-RELATION  OF  VARIOUS   SOCIAL  EF- 
FORTS     144-156 

The  Possibilities  of  Good  Work  under  Present  Economic 

Conditions. 

The  Importance  of  Social  Work  to  the  Physician. 
The  Constant  Need  for  a  Causal  Outlook. 
Poverty  and  Disease. 


Xll  CONTENTS 

Causes  of  Intemperance. 

The  Causation  and  Prevention  of  Venereal  Diseases. 
Lop-sided  Views  as  to  Ignorance  in  Causation  of  Disease. 

LECTURE  VII 

THE  OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROG- 
RESS     157-182 

Degree  of  Progress  Realized. 

Obstacle  of  Urban  Life. 

Obstacle  of  Industrialism. 

Obstacle  of  Poverty. 

The  Influence  of  the  Malthusian  Hypothesis. 

Obstacle  of  Ignorance. 

Obstacle  of  Defects  of  Character. 

IDEALS. 

Communal  Action. 

Spread  of  Altruism. 

Supreme  Importance  of  Mother  and  Child. 

LECTURE  VIII 

SOME  ASPECTS  OF  POVERTY 183-190 

Disease  a  Chief  Cause  of  Poverty. 

Diminution  of  Poverty  apart  from  Increased  Family  Income. 

Poverty  a  Complex. 

Action  Needed  against  Each  Constituent  Element  of  Poverty. 

LECTURE  IX 

THE    CAUSATION    OF    TUBERCULOSIS    AND    THE 
MEASURES  FOR  ITS  CONTROL  IN  ENGLAND.  .   191-239 

A.  Basic  Facts  as  to  Tuberculosis. 

Explanations  of  the  Decreasing  Death-rate  from  Tuber- 
culosis. 


CONTENTS  xiii 

Diminished  Virulence  of  the  Tubercle  Bacillus. 

Increased  Human  Resistance  by  Natural  Selection. 

Immunization  by  Small  Doses  of  the  Contagium. 
Diminished  Tuberculosis  with  Increased  Aggregation  of 
Population. 

Hospital  Treatment  of  Consumptives. 
Koch's  Views  as  to  Hospital  Segregation. 
Improved  Housing  in  Reduction  of  Tuberculosis. 

B.  Measures  of  Control. 

Notification  of  Cases. 

Causes  of  Failure  in  Notification. 
Public  Health  Action  following  Notification. 
Examination  of  Contacts. 
Scope  of  Tuberculosis  Schemes. 
Tuberculosis  Dispensaries. 

Should  be  Part  of  General  Dispensaries. 
The  Home  Visitation  of  Patients. 
Sanatorium  Benefit 
Residential  Institutions. 

General  Observations  on  Treatment  in  Sanatoria. 
Hospital  Treatment. 
Industrial  Colonies. 

Special  Dwellings  and  Help  in  Support. 
Summary. 


LECTURE  X 

CHILD  WELFARE  WORK  IN  ENGLAND 240-267 

The  Earlier  Work  of  Medical  Officers  of  Health. 
The  Notification  of  Births. 
Chief  Causes  and  Course  of  Infant  Mortality. 
The  Influence  of  School  Medical  Inspection. 
The  Influence  of  Statistical  Studies. 


Xiv  CONTENTS 

The  Midwives  Acts. 

Health  Visiting. 

Voluntary  Work. 

Child  Welfare  Centers. 

Training  and  Provision  of  Midwives. 

Ante-natal  Work. 

Dental  Assistance. 

Creches. 

Observation  Beds  at  Child  Welfare  Centers. 

Grants  to  Local  Authorities. 

Course  of  Mortality  in  Childbearing. 


CHAPTER  I 

PUBLIC  HEALTH  PROGRESS  IN  ENGLAND  DURING  THE 
LAST  FIFTY  YEARS1 

After  thirty-five  years  in  active  public  health  work 
in  England — during  eleven  of  those  years  having  been 
the  principal  officer  of  its  central  public  health  depart- 
ment on  its  medical  side — I  may  be  assumed  to  possess 
some  qualification  for  the  task  of  reviewing  the  past 
half  century's  progress  in  public  health  in  England. 

Parallelism  of  Events  in  New  and  Old  England 

I  find  it,  however,  beyond  my  power  to  compass 
in  a  short  address  a  resume  of  my  subject  which  shall 
be  complete,  or  completely  in  perspective,  or  which 
shall  not  omit  features  on  which,  had  time  permitted, 
one  would  have  wished  to  comment;  and  I  must  ask 
you  to  remember  that  only  a  portion — and  that  chiefly 
non-administrative2 — of  the  history  of  this  wonderful 
half  century  can  be  embraced  within  the  present  ad- 
dress. The  survey  should,  I  think,  take  a  panoramic 
view  of  the  story  as  it  has  developed,  should  note  the 

1  An  address  prepared   for  the  celebration  of  the  fiftieth 
anniversary  of  the  Massachusetts  Board  of  Health,  Septem- 
ber, 1919. 

2  The  administrative  side  of  the  subject  is  sketched  in  the 
next  chapter. 

2  I 


2  PUBLIC    HEALTH    PROGRESS    IN    ENGLAND 

changes  as  they  have  occurred,  the  obstacles  which 
impeded  reforms  as  well  as  the  reforms  secured ;  and 
should  also,  at  least  incidentally,  state — in  the  light  of 
unfailing  historical  guidance,  as  well  as  of  increasing 
knowledge — the  pressing  desiderata  for  more  efficient 
and  more  rapid  future  progress.  I  cannot  hope  to 
accomplish  this  task  except  to  a  fragmentary  extent, 
but  I  am  happy  to  remember  that  sanitary  history  in 
Old  and  in  New  England  has  proceeded  largely  on 
parallel  lines.  The  curves  of  annual  death-rates  from 
all  causes,  from  typhoid  fever,  from  tuberculosis,  and 
of  the  mortality  of  infants  show  the  closeness  of  the 
parallelism  of  the  public  health  history  of  England  and 
Massachusetts. 

The  work  of  the  last  fifty  years  was  built  on  pre- 
ceding pioneer  work  of  men  in  Old  and  in  New  Eng- 
land ;  and  for  a  complete  understanding  of  this  work, 
a  momentary  glance  is  required  at  the  men  of  this 
earlier  generation  and  their  work. 

In  the  old  country  we  speak  with  reverence  of  the 
names  of  Southwood  Smith,  Kay,  Chadwick,  Farr  and 
Simon;  and  you  remember  with  gratitude  the  names 
of  Lemuel  Shattuck,  of  Bowditch,  of  Walcott,  S.  W. 
Abbott,  and  Theobald  Smith;  and  it  is  gratifying  to 
remember  that  the  epoch-making  report  of  the  Massa- 
chusetts Sanitary  Commission  of  1850 — to  which  were 
attached  the  ever  memorable  names  of  Shattuck,  N.  P. 
Banks,  and  Jehiel  Abbott — among  its  many  statesman- 


DURING   THE   LAST   FIFTY   YEARS  3 

like  and  far-seeing  proposals,  recommended  a  sanitary 
survey  of  the  State,  and  referred  to  the  recent  English 
sanitary  surveys,  with  which  British  sanitation  may  be 
said  to  have  begun. 

The  Utilisation  of  Lay  Workers 

Let  me  in  passing  comment  on  the  fact  that  neither 
Lemuel  Shattuck  in  Boston  nor  Edwin  Chadwick  in 
London  was  a  physician ;  but  a  perusal  of  their  writ- 
ings shows  that  they  were  men  of  sound  judgment,  of 
earnest  zeal  for  their  fellow  men,  with  a  wide  and 
statesmanlike  outlook,  ready  to  search  out,  to  accept 
and  to  apply  the  medical  knowledge  on  which  neces- 
sarily the  prevention  of  disease  is  based.  They  illus- 
trate once  for  all  the  need  for  partnership  between  all 
well-wishers  of  humanity  in  this  work,  and  the  impor- 
tance of  combined  effort  by  the  sociologist  and  the 
physician,  as  well  as  of  experts  in  each  branch  of  sani- 
tation, if  all  attainable  success  is  to  be  attained. 

The  tradition  then  established  has  never  been  lost. 
In  England,  more  perhaps  than  in  America,  the  control 
of  public  health  work  has  been  shared  by  intelligent 
laymen  on  local  and  central  authorities,  and  the  fact 
that  medical  officers  of  health  have  found  it  necessary 
to  convince  these  lay  representatives  of  the  general 
public  of  the  need  for  the  reforms  recommended,  has 
led  to  steady  progress,  seldom  interrupted  by  relapses. 
And  this  is  true,  although  delays  and  disappoint- 


4  PUBLIC   HEALTH   PROGRESS   IN   ENGLAND 

ments  have  beset  the  path  of  the  earnest  reformer, 
who  might  well  wish  that  his  lay  colleagues  had  been 
trained  in  schools  in  which  natural  science  formed  a 
more  open  avenue  to  distinction  than  classics ;  or  that 
the  representatives  on  local  authorities  might  more 
fully  and  more  quickly  appreciate  in  Simon's  words, 
what  they  are 

sometimes  a  little  apt  to  forget  that,  for  sanitary  purposes, 
they  are  also  the  appointed  guardians  of  human  beings  whose 
lives  are  at  stake  in  the  business. 

What  were  the  ideals  with  which  the  Fathers  of 
Sanitation  in  New  and  in  Old  England  began  their 
work? 

They  cannot  be  better  expressed  than  in  their  own 
words.  In  the  1850  Report  of  the  Massachusetts 
Sanitary  Commission  they  are  thus  expressed : 

We  believe  that  the  conditions  of  perfect  health,  either 
public  or  personal,  are  seldom  or  never  attained,  though  at- 
tainable; that  the  average  length  of  human  life  may  be  very 
much  extended,  and  its  physical  power  greatly  augmented; 
that  in  every  year,  within  this  Commonwealth,  thousands  of 
lives  are  lost  which  might  have  been  saved ;  that  tens  of  thou- 
sands of  cases  of  sickness  occur,  which  might  have  been  pre- 
vented; that  a  vast  amount  of  unnecessarily  impaired  health, 
and  physical  debility,  exists  among  those  not  actually  confined 
by  sickness;  that  these  preventible  evils  require  an  enormous 
expenditure  and  loss  of  money,  and  impose  upon  the  people 
unnumbered  and  immeasurable  calamities,  pecuniary,  social, 
physical,  mental,  and  moral,  which  might  be  avoided;  that 
means  exist,  within  our  reach,  for  their  mitigation  or  re- 
moval ;  and  that  measures  for  prevention  will  effect  infinitely 
more  than  remedies  for  the  cure  of  disease. 


DURING  THE   LAST  FIFTY   YEARS  5 

In  a  succeeding  paragraph  the  Commissioners  pro- 
ceed to  quote  with  approval,  the  following  remarks 
made  by  Mr.  (afterwards  Sir  John)  Simon  in  the 
preceding  year,  when  he  was  medical  officer  of  health 
to  the  City  of  London,  and  before  he  became  the  prin- 
cipal medical  officer  and  adviser  of  the  British  Govern- 
ment in  health  matters,  and  in  that  capacity  laid  the 
foundation  and  built  much  of  the  edifice  of  our  pres- 
ent health  organization. 

Ignorant  men  may  sneer  at  the  pretensions  of  sanitary  sci- 
ence; weak  and  timorous  men  may  hesitate  to  commit  them- 
selves to  its  principles,  so  large  is  their  application ;  selfish 
men  may  shrink  from  the  labour  of  change,  which  its  recog- 
nition must  entail;  and  wicked  men  may  turn  indifferently 
from  considering  that  which  concerns  the  health  and  happi- 
ness of  millions  of  their  fellow-creatures ;  but  in  the  great 
objects  which  it  proposes  to  itself,  in  the  immense  ameliora- 
tion which  it  proffers  to  the  physical,  social,  and,  indirectly,  to 
the  moral  conditions  of  an  immense  majority  of  our  fellow 
creatures,  it  transcends  the  importance  of  all  other  sciences ; 
and,  in  its  beneficent  operation,  seems  to  embody  the  spirit, 
and  to  fulfil  the  intentions,  of  practical  Christianity. 

With  such  noble  ideals,  what  measure  of  success 
crowned  their  efforts  and  those  of  their  successors  ? 

The  earlier  history  I  can  only  briefly  mention,  as  we 
are  chiefly  concerned  today  with  events  since  1869. 
To  understand  these  events,  however,  one  must  under- 
stand the  forces  which  had  been  accumulating  and 
increasing  in  power  in  earlier  years,  and  which  ren- 
dered possible  the  rapid  public  health  progress  expe- 


6  PUBLIC   HEALTH   PROGRESS   IN   ENGLAND 

rienced  in  the  fourth  quarter  of  the  nineteenth  and  the 
first  quarter — so  far  as  it  has  passed — of  the  twen- 
tieth century. 

Laissez  Faire  Economic  Teaching 

Historians  in  future  generations  will  refer  to  the 
second  half  of  the  eighteenth  and  the  first  half  of  the 
nineteenth  century  as  the  period  of  unmitigated  indus- 
trialism, of  associated  rapid  increase  of  urban  at  the 
expense  of  rural  life,  and  of  the  most  extreme  mani- 
festation of  laissez  faire  economic  science.  The  older 
semi-paternal  system  of  interference  with  the  eco- 
nomic life  of  the  people  by  King  and  Parliament,  was 
replaced,  under  the  influence  of  Adam  Smith,  Malthus, 
James  Mill,  and  other  teachers,  by  inaction  based  on 
the  view  that  in  old  countries  poverty  is  the  natural 
and  inevitable  result  of  pressure  of  population  on 
means  of  subsistence,  and  that  any  interference  with 
freedom  of  competition  in  obtaining  work  or  employ- 
ing workers  is  useless  or  mischievous.  A  similar  view 
found  expression  in  President  Jefferson's  dictum :  that 
government  is  best  which  governs  least ;  and  until  the 
middle  of  the  nineteenth  century  these  views  were  gen- 
erally accepted  and  their  influence  was  dominant. 

It  was  assumed  that  given  free  competition,  enlight- 
ened self-interest  would  incite  effort  and  improvement, 
encourage  self-reliance,  and  guarantee  production  and 
economy. 


DURING   THE   LAST   FIFTY   YEARS  7 

Under  the  conditions  considered  inevitable  with  such 
teaching,  although  great  wealth  accompanied  the  rapid 
industrial  development  after  the  Napoleonic  wars,  it 
was  associated  with  unrelieved  misery;  for  home- 
workers  and  rural  workers  crowded  into  mean  hovels 
in  towns,  paying  exorbitant  rents  out  of  a  miserable 
pittance  of  wages,  and  were  exposed  to  the  evils  result- 
ing from  overcrowding,  and  from  absence  of  adequate 
and  satisfactory  water  supply,  scavenging  or  drainage. 
By  the  year  1851  about  half  the  population  of  England 
and  Wales  had  become  aggregated  in  towns;  and  it 
may  be  added  that  in  1911,  less  than  one  fourth  of  the 
population  was  left  in  rural  districts.  Urbanization 
in  the  earlier  years  meant  dense  overcrowding  and  in- 
sanitation;  and  that  it  is  still  an  influence  adverse  to 
health  may  be  gathered  from  the  information  given 
by  the  census  of  1911,  that  over  eight  times  as  large 
a  proportion  of  the  urban  as  of  the  rural  population 
live  in  one-roomed  tenements,  and  nearly  twice  as  large 
a  proportion  live  in  two-roomed  tenements,  while  the 
proportion  of  one-roomed  tenements  in  towns  which 
are  overcrowded  (in  the  sense  of  having  more  than 
two  persons  to  a  room)  in  towns  is  seven  times  as 
great,  and  of  two-roomed  tenements  is  twice  as  great 
as  in  country  districts. 

Domestic  misery  was  associated  with  commensurate 
industrial  misery ;  overwork,  in  insanitary  factories 
and  workshops,  regardless  of  the  health  of  the  "hands," 
was  the  rule. 


8  PUBLIC   HEALTH   PROGRESS   IN   ENGLAND 

The  displacement  between  1760  and  1800  of  do- 
mestic by  factory  manufacture  represented  a  new 
phenomenon  in  the  world's  history,  a  true  industrial 
revolution.  It  was  the  parting  of  the  ages;  destined 
not  only  to  change  the  life  of  the  people  of  England 
from  preponderantly  outdoor  to  preponderantly  in- 
door; and  to  bring  for  them  for  many  years  all  the 
disadvantages  of  unregulated  town  life;  but  also, 
owing  to  the  rapid  development  of  better  roads,  of 
canals,  and  then  of  railroads  and  steamships  to  end 
forever  the  practical  segregation  in  which  countries, 
and  even  neighbouring  communities,  had  previously 
lived. 

It  cannot  be  wondered  at  that  under  these  circum- 
stances the  general  death-rate  was  excessive,  and  epi- 
demic disease  spread  with  a  rapidity  and  to  an  extent 
previously  unknown. 

The  reaction  against  the  laissez  faire  economic 
teaching  began  early,  and  it  is  in  accordance  with  the 
fitness  of  things  that  the  national  conscience  first  re- 
belled. The  earliest  evidence  of  reform  was  legisla- 
tion in  1802  on  behalf  of  pauper  children  indentured 
to  the  overseers  in  textile  factories ;  and  there  followed 
subsequent  Factory  and  other  Acts  in  1819,  in  1833, 
in  1844  and  in  1847,  which  prohibited  the  factory  em- 
ployment of  children  under  nine,  limited  the  hours  of 
labour  of  young  persons  and  of  women,  and  insisted 
on  elementary  sanitation  in  factories.  Subsequent 


DURING  THE  LAST  FIFTY  YEARS  9 

Factory  and  Mining  Acts,  followed  by  Shop  Hours 
Acts  and  the  Shop  Seats'  Act,  have  completed  a  most 
valuable  code  of  regulations  prohibiting  overwork, 
and  securing  a  measure  of  protection  against  dangers 
to  health  and  limb  or  eyesight  during  industrial  em- 
ployment. It  is  noteworthy  that  the  first  steps  at  im- 
proved sanitation,  and  to  safeguard  health  by  prevent- 
ing overwork,  were  on  the  industrial  plane.  Factory 
inspectors  preceded  medical  officers  of  health  and  sani- 
tary inspectors  appointed  by  local  authorities. 

Philanthropy  was  the  motive  power  in  initiating  fac- 
tory reform ;  in  securing  general  sanitary  reform,  driv- 
ing power  was  furnished  by  the  double  motive  of 
economy  and  fear,  caused  by  the  inordinate  expense 
of  poor-law  administration,  the  frequently  recurring 
epidemics  of  "  fever,"  and  the  alarming  occasional  in- 
vasions of  Asiatic  cholera.  The  sacrifices  of  life  from 
cholera  were  truly  vicarious ;  for  we  owe  it  largely  to 
these  that  our  national  system  of  vital  statistics  was 
initiated  in  1837  and  that  serious  efforts  at  sanitary 
reform  were  begun. 

Man  and  His  Environment 

The  history  of  these  earlier  steps  is  full  of  interest ; 
but  I  cannot  outline  it  today.  There  can  be  no  doubt 
that  as  Simon3  put  it,  referring  to  Dr.  Southwood 
Smith's  report  to  the  Poor-Law  Commissioners  in 

8  Reprint  of  Reports,  Vol.  I,  p.  448. 


IO  PUBLIC   HEALTH   PROGRESS   IN   ENGLAND 

1838  ("on  Some  of  the  Physical  Causes  of  Sickness 
and  Mortality  to  which  the  Poor  are  particularly  ex- 
posed, and  which  are  capable  of  removal  by  Sanitary 
Regulations  ") 

the  commencement  of  State  interference  on  behalf  of  the 
health  of  the  labouring  classes  may  be  said  to  date  from  its 
publication  and  to  have  been  in  a  very  important  degree  deter- 
mined by  its  facts  and  arguments. 

That  the  first  principles  of  causation  were  beginning 
to  be  appreciated  is  shown  in  the  following  extract 
from  Queen  Victoria's  speech  in  opening  Parliament 
in  1849.  ^n  this  speech  she  referred  to  the  ravages 
of  cholera  which  it  had  pleased  Almighty  God  to  ar- 
rest, and  added : 

Her  Majesty  is  persuaded  that  we  shall  best  evince  our 
gratitude  by  vigilant  precautions  against  the  more  obvious 
causes  of  sickness,  and  an  enlightened  consideration  for  those 
who  are  most  exposed  to  its  attacks. 

Note  that  these  words  and  the  early  attempts  at  public 
health  legislation,  culminating  in  our  great  sanitary 
code,  the  Public  Health  Act,  1875,  incorporated  the 
tripod  on  which  enlightened  public  health  administra- 
tion must  always  be  supported,  viz., 

(1)  attack  on  the  causes  of  sickness, 

(2)  satisfactory  treatment  of  the  sick,  and 

(3)  satisfactory  care  for  the  poor. 

I  might  properly  add 

(4)  attack  on  the  causes  of  poverty, 


DURING   THE   LAST   FIFTY   YEARS  II 

for  it  is  perhaps  the  chief  merit  of  the  great  work  of 
Edwin  Chadwick  that,  in  the  light  of  reports  on  local 
surveys  made  by  Kay,  Southwood  Smith,  and  others, 
he  was  convinced  and  was  able  to  convince  Parliament 
that  a  very  large  share  of  the  total  destitution  then  ex- 
isting was  due  to  the  conditions  under  which  the  people 
lived,  and  the  disease  generated  in  these  conditions. 

It  is  commonly  stated  that,  in  the  past,  public  health 
administration  has  concerned  itself  solely  with  man- 
kind's environment/ failing  to  recognise  the  predomi- 
nant importance  of  man  himself  as  a  transmitter  of 
disease,/and  of  his  personal  well-being  and  protection 
as  the  point  to  which  energy  should  be  directed.  This 
cannot  be  said  to  have  been  the  intention  of  the  legisla- 
ture or  of  the  earlier  reformers ;  though  unhappily  this 
limited  view  received  official  acceptance,  in  large  meas- 
ure owing  to  the  increasing  incompatibility  between 
poor-law  and  public  health  administration  and  the 
spreading  over  from  poor-law  to  public  health  admin- 
istration of  the  general  influence  of  "  deterrence  "  as  a 
motive  of  administration.  As  time  went  on,  this  prin- 
ciple came  to  be  realised  as  contrary  to  the  general 
interest  in  anything  which  concerns  the  health  of  the 
community. 

Dirt  and  Disease 

The  crude  generalization  emerging  from  the  earlier 
surveys  was  the  close  relation  between  filth  conditions 
and  excessive  sickness;  and  the  motive  behind  these 


12  PUBLIC    HEALTH    PROGRESS    IN   ENGLAND 

inquiries  was  the  desire  to  remove  one  of  the  chief 
causes  of  destitution. 

So  late  as  1874  Simon  said  "filth  is  the  deadliest  of 
our  present  removable  causes  of  disease" ;  and  through- 
out the  whole  series  of  his  vividly  worded  and  in- 
fluential reports,  the  same  fundamentally  important 
teaching  was  urged. 

Chadwick's  earlier  reports  were  similarly  influenced 
by  the  teaching  of  Dr.  Southwood  Smith  and  his  col- 
laborators, to  the  effect  that  epidemic  diseases  as  a 
whole  are  the  direct  consequence  of  local  insanitary 
conditions.  This  generalization,  as  we  now  know, 
needs  a  modified  and  more  accurate  statement,  special- 
ized for  each  individual  disease.  In  its  original  form, 
however,  it  embodied  a  realisation  of  the  immense  im- 
portance of  the  environment  to  make  or  to  mar  indi- 
vidual and  national  life;  it  secured  the  beginning  of 
our  national  sanitary  improvements,  and  it  laid  the 
foundations  of  the  house  of  health  which  as  nations 
we  are  still  building. 

The  three  diseases  which  were  especially  regarded 
as  due  to  filth  were  cholera,  typhus,  and  enteric  fever ; 
and  the  history  of  public  health  in  England  is  largely 
concerned  with  these  three  diseases. 

Cholera 

The  general  view  then  held  in  New  as  in  Old  Eng- 
land is  well  stated  in  the  following  extract  from  the 


DURING   THE   LAST   FIFTY   YEARS  13 

Report  of  the  Massachusetts  Sanitary  Commission, 
1850: 

Atmospheric  contagion  is  generally  harmless  unless  attracted 
by  local  causes  .  .  .  that  terrible  disease,  Asiatic  Cholera, 
derives  its  terrific  power  chiefly  or  entirely  from  the  accessory 
or  accompanying  circumstances  which  attend  it.  It  bounds 
over  habitation  after  habitation  where  cleanliness  abides ; 
.  .  .  while  it  alights  near  some  congenial  abode  of  filth  or 
impurity.  .  .  .  Wherever  there  is  a  dirty  street,  court,  or 
dwelling-house,  the  elements  of  pestilence  are  at  work  in  that 
neighbourhood. 

And  the  important  moral  is  drawn  that 

the  person  who  permits  his  neighbour's  atmosphere  to  be  con- 
taminated by  any  filth  ...  is  worse  than  a  highway  robber. 
The  latter  robs  us  of  property,  the  former  of  life. 

Similarly,  Simon  in  England  was  teaching  that  "in 
order  to  the  prevention  of  Filth  Diseases,  the  preven- 
tion of  filth  is  indispensable" ;  and  that  there  was  need 
for  local  authorities  "  to  introduce  for  the  first  time, 
as  into  savage  life,  the  rudiments  of  sanitary  civili- 
zation." 

The  crude  generalization  that  filth  causes  disease 
perhaps  persisted  too  long,  and  the  value  of  Snow's 
investigation  in  1855  of  the  outbreak  of  Cholera  in 
the  area  of  supply  of  the  Broad  Street  pump  was 
perhaps  too  slowly  appreciated.  The  influence  of 
Von  Pettenkofer's  theories  on  the  relation  between 
subsoil  conditions  and  Cholera  was  largely  responsible 
for  this  delay;  but  already  in  1856  Simon  had  accepted 


14  PUBLIC   HEALTH   PROGRESS   IN   ENGLAND 

the  importance  of  water  infection,  giving  as  his  gen- 
eral conclusion  that 

under  the  specific  influence  which  determines  an  epidemic 
period,  fecalised  drinking  water  and  fecalised  air  equally  may 
breed  and  convey  the  poison  (of  Cholera). 

Still  it  will  be  noted  there  persisted  the  notion  of 
aerial  convection  of  the  contagia  of  cholera  and  enteric 
fever,  in  addition  to  their  convection  by  dirt,  by  flies, 
or  the  more  common  contamination  of  hands  or  feet 
or  food  by  faecal  matter ;  but  the  importance  of  water 
supplies  was  beginning  to  be  appreciated.  Already  in 
1883  local  authorities  in  England  and  Wales  had  out- 
standing loans  for  waterworks  amounting  to  twenty- 
nine  million  and  for  sewerage  amounting  to  fifteen 
million  pounds  sterling,  while  between  1883  and  1912 
they  expended  out  of  rates  and  by  means  of  loans  one 
hundred  and  thirty-one  millions  for  waterworks  and 
eighty-nine  millions  sterling  for  sewerage. 

Although  we  realise  now  the  greater  importance  of 
control  of  excreta  from  persons  specifically  infected, 
we  must  agree  with  Simon  that  communally 

Nowhere  out  of  Laputa  could  there  be  serious  thought  of 
differentiating  excremental  performances  into  groups  of  diar- 
rhoeal  and  healthy.  ...  It  is  excrement,  indiscriminately,  that 
must  be  kept  from  fouling  us  with  its  decay.  ...  It  is  to  be 
hoped  that  .  .  .  for  a  population  to  be  thus  poisoned  by  its 
own  excrement,  will  some  day  be  deemed  ignominious  and 
intolerable. 

And  it  is  still  opportune  to  draw  attention  to  the  ter- 


DURING   THE   LAST   FIFTY   YEARS  15 

rible  responsibility  incurred  by  local  authorities  when 
they  distribute  a  general  supply  of  water  to  the  inhabi- 
tants of  their  area  without  taking  every  possible  pre- 
caution against  contamination.  The  conveniences  and 
advantages  of  public  water  supplies  "are  countervailed 
by  dangers  to  life  on  a  scale  of  gigantic  magnitude  " ; 
and  sanitary  history,  in  the  calamitous  experience  of 
Lincoln,  Maidstone,  and  Worthing  and  of  Lowell  and 
other  towns  and  districts,  has  given  remarkable  illus- 
trations of  the  need  for  eternal  vigilance. 

Typhoid  Fever. 

With  the  differentiation  of  typhoid  fever  from 
typhus  fever  by  Gerhard  in  Philadelphia  in  1837,  and 
by  Stewart  and  W.  Jenner  in  Great  Britain  in  1849,  ^ 
became  possible  to  associate  the  former  with  excre- 
mental,  the  latter  with  respiratory  filth,  "the  non- 
removal  of  the  volatile  refuse  of  the  human  body." 
The  question  still  remained  whether  typhoid  fever  was 
producible  by  "  emanations  from  decomposing  organic 
matter,"  whether  it  was  "  often  generated  sponta- 
neously by  faecal  fermentation,"  as  contended  by 
Murchison,  who  in  1858  proposed  the  name  "pytho- 
genic  fever"  for  typhoid  fever;  or  whether  as  indi- 
cated by  the  remarkable  observations  of  William  Budd 
of  Bristol,  the  introduction  of  specific  infection  from  a 
typhoid  patient  was  needed  to  start  a  local  outbreak. 
Gradually  it  became  clear  that  specific  contamination 


1 6  PUBLIC    HEALTH    PROGRESS   IN    ENGLAND 

was  necessary  to  start  an  outbreak  or  even  to  cause  a 
single  case  of  this  disease,  and  between  1870  and  1880 
a  number  of  water-borne  outbreaks  were  traced.  It 
also  gradually  became  evident  that,  however  objection- 
able or  even  noxious  might  be  the  gaseous  emanations 
from  leaky  drains  or  sewers,  they  did  not  cause  typhoid 
fever  or  diphtheria.  Hence  the  statement,  for  in- 
stance, of  Oliver  Wendell  Holmes  in  1862  (quoted  for 
its  historical  interest  by  Dr.  Sedgwick)  that  "  the  bills 
of  mortality  are  more  obviously  affected  by  drainage 
than  by  this  or  that  method  of  practice,"  which  ex- 
pressed universal  opinion  when  it  was  written,  is  now 
known  to  be  accurate  only  when  specific  matter  from 
drains  contaminates  milk  or  water  supplies,  or  causes 
infection  by  actual  contact. 

With  the  general  recognition  of  the  causal  relation 
between  impure  water  supplies  and  typhoid  fever  came 
the  rapid  provision  of  public  supplies,  on  which,  as 
already  seen,  large  public  expenditure  was  incurred; 
and  to  this  fact  is  owing,  in  the  main,  the  rapid  reduc- 
tion in  typhoid  mortality  shown  in  the  following  state- 
ment: 


Year 
1871     

Population  of  Eng- 
land and  Wales 
in  Millions 

22^ 

No.  of  Deaths 
from  Typhoid 
Fever 

12  70O 

1881    

26 

6,688 

1801    , 

29 

C.2OO 

IOOI     . 

.    V% 

5.172 

IOII     , 

.    16^ 

2.43O 

1917    33%  (civilian)  97? 


DURING   THE   LAST   FIFTY   YEARS  17 

The  number  of  cases  notified  in  England  and  Wales 

in  1911  was  13,852 
in  1917  was    4,601 

There  was,  it  will  be  noted,  a  period  of  apparent 
cessation  of  decline  in  the  typhoid  mortality  between 
1891  and  1901,  followed  by  a  striking  decline  between 
1901  and  the  present  time.  The  late  decline  was  due 
in  large  measure  to  the  discovery  of  the  relation  be- 
tween contaminated  shell-fish  and  enteric  fever,  and, 
probably  to  a  less  extent,  to  the  realisation  of  the  im- 
portance of  the  small  minority  of  cases  of  this  dis- 
ease, who  continue  after  their  recovery  to  spread  in- 
fection. At  the  present  time  typhoid  fever  promises 
to  become  as  rare  in  England  as  typhus  fever  or  ma- 
laria; and  with  increased  care  in  the  protection  of 
food,  as  well  as  of  water  supplies,  and  with  the  uni- 
versal hospital  treatment  of  the  sick  and  observation 
of  their  bacterial  condition  on  discharge,  this  antici- 
pation bids  fair  to  be  realised. 

Typhus  Fever 

The  history  of  typhus  is  similar  to  that  of  typhoid 
fever;  and  when  Murchison  in  1858  asserted  its  spon- 
taneous generation  under  conditions  of  overcrowding 
and  bad  ventilation — 

Its  great  predisposing  cause  is  destitution;  while  the  excit- 
ing cause  or  specific  poison  is  generated  by  overcrowding  of 
human  beings  with  deficient  ventilation — 

3 


1 8  PUBLIC    HEALTH    PROGRESS   IN    ENGLAND 

he  was  expressing  the  considered  conclusion  of  his 
period. 

Typhus  Fever  was  not  differentiated  from  enteric 
fever  in  the  Registrar-General's  returns  prior  to  1869, 
but  the  course  of  events  in  later  periods  can  be  seen 
in  the  following  statement : 

Typhus  Feyer,  No. 
of  Deaths  in  Eng- 
Vean  land  and  Wales 

Ten  years,  1871-80 13,975 

Eight  years,  1903-10  210 

Seven  years,  191 1-17  42 

The  cases  in  recent  years  were  nearly  all  traceable 
to  imported  infection. 

The  main  factors  in  the  reduction  of  typhus  fever 
have  been  the  immobilisation  of  infectious  cases  in 
fever  hospitals,  the  rigid  cleansing  and  disinfection  of 
invaded  households,  and  the  surveillance  of  persons 
who  have  been  exposed  to  infection.  The  clearing  of 
insanitary  courts,  housing  improvements,  and  the  asso- 
ciated increased  cleanliness  of  the  general  population 
have  doubtless  aided;  and  it  is  a  suggestive  fact  that 
although  the  virus  of  typhus  is  not  yet  determined,  and 
although  it  has  only  recently  been  shown  that  typhus 
is  a  louse-spread  disease,  the  point  of  extinction  of  the 
disease  under  peace  conditions  has  almost  been  reached 
in  countries  having  an  efficient  sanitary  organization 
and  a  cleanly  people. 

With  the  demonstration  that  typhoid  fever  was  com- 


DURING   THE   LAST   FIFTY   YEARS  19 

monly  water-borne,  that  the  spread  of  typhus  fever 
could  be  controlled  by  sanitary  surveillance  and  im- 
mobilisation of  infectious  cases  in  hospital,  and  that 
diarrhoeal  mortality  could  be  reduced  by  increased 
municipal  and  domestic  cleanliness,  much  more  rapid 
improvement  in  national  health  occurred  in  the  decen- 
nium  1871-1880  and  in  subsequent  years. 

The  course  of  events  for  typhoid  and  typhus  fever 
has  already  been  noted.  Before  describing  further 
the  action  taken  by  central  and  local  public  health  au- 
thorities and  the  other  influences  conducing  to  reform, 
it  is  convenient  to  summarise  at  this  point  the 

General  Results  in  the  Saving  of  Life 

Although  I  do  not  dwell  further  on  the  influence  of 
increase  of  wages,  of  better  and  cheaper  food,  of  sani- 
tary education  of  the  people,  of  a  steadily  increasing 
standard  of  cleanliness, — in  person  and  in  spitting 
habits, — and  of  improving  home  conditions,  it  will  not 
be  assumed  they  must  be  omitted  in  any  considered 
judgment  as  to  the  means  by  which  the  saving  of  life 
shown  by  the  following  figures  has  been  secured. 

The  expectation  of  life  at  birth  (or  mean  after- 
lifetime)  in  England  and  Wales  in  1871-80  for  males 
was  41.4  years,  for  females  41.9  years.  It  steadily 
improved  decade  by  decade;  based  on  the  experience 
of  1910-12  the  male  expectation  of  life  had  been  pro- 
longed by  10.1  years,  and  the  female  by  10.8  years.  A 


2O  PUBLIC   HEALTH   PROGRESS   IN   ENGLAND 

very  large  proportion  of  the  lives  saved  were  lived  in 
the  years  of  greatest  value  to  the  community.  Com- 
paring 1910-12  with  1871-80,  the  reduction  of  the 
death-rate  meant  that  each  year  116,401  male  and 
118,554  female  lives  were  saved,  and  the  future  life- 
time of  these  persons  whose  lives  were  prolonged, — 
assuming  a  continuance  of  current  experience, — would 
give  an  annual  gain  of  nearly  ten  millions  of  additional 
years  of  life,  of  which  over  seventy  per  cent,  would  be 
lived  at  ages  15  to  65. 

Of  the  annual  saving  of  234,955  lives,  64  per  cent, 
was  ascribable  to  reduced  mortality  from  acute  and 
chronic  infectious  diseases ;  and  of  the  mortality  under 
these  headings  nearly  one-third  was  referable  to  re- 
spiratory diseases,  the  same  amount  to  tuberculosis, 
one-seventh  to  scarlet  fever,  one-thirteenth  to  measles 
and  whooping  cough,  the  same  amount  to  typhus  and 
enteric  fever,  and  one-sixteenth  to  diarrhoeal  diseases. 

The  gain  of  life  may  be  further  illustrated  by  the 
following  figures.  During  the  32  years,  1881  to  1912, 
over  seventeen  millions  deaths  occurred  in  England 
and  Wales.  Had  the  experience  of  1871-80  continued 
throughout  the  subsequent  years,  the  number  of  deaths 
would  have  been  increased  by  close  on  four  millions. 

Specific  Causation  of  Disease 

The  preceding  review  will  have  made  it  clear  that  in 
the  period  of  earlier  slow  sanitary  reform,  although 


DURING   THE   LAST   FIFTY   YEARS  21 

much  invaluable  work  was  being  done,  it  was  in  some 
measure  a  groping  in  the  dark,  a  continuous  search  for 
further  light  while  pursuing  (or  at  least  advocating  in 
season  and  out  of  season)  such  cleansing  and  purifica- 
tion of  man's  surroundings  as  were  evidently  needed, 
and  such  segregation  of  the  infectious  sick  as  could  be 
secured  in  the  absence  of  complete  information  of  the 
cases  of  sickness.  Happily  in  the  case  of  Small  Pox 
there  was  an  additional  effective  protection  in  vacci- 
nation. 

With  Pasteur's  discoveries  was  inaugurated  a  new 
era  in  sanitation ;  the  general  microbial  origin  of  infec- 
tious diseases,  inferred  from  his  discoveries,  leading  to 
the  conclusion  that  the  chief  source  of  disease  to 
others  is  man  himself,  and  that  his  surroundings  in  the 
main  cause  disease  insofar  only  as  they  become  a  ve- 
hicle for  conveying  disease  by  direct  inhalation  of 
infected  dirt  (Sax.  drit  =  excrement),  or  by  swallow- 
ing specifically  infected  foods. 

The  importance  of  the  sanitary  engineer  in  securing 
pure  water  supplies  and  satisfactory  sewerage  con- 
tinues. The  sanitary  inspector's  work  in  removing 
nuisances  and  accumulations,  any  one  of  which  might 
be  specifically  contaminated,4  and  in  controlling  over- 
crowding and  uncleanliness  as  well  as  in  other  respects, 

4  There  is  still  no  evidence  to  show  that  in  the  production 
of  the  excessive  diarrhoea  which  prevails  in  insanitary  dis- 
tricts, specific  contamination  of  the  filth  accumulations  is 
necessary. 


22  PUBLIC    HEALTH    PROGRESS    IN    ENGLAND 

remains  indispensable.  But  the  brunt  of  guidance  in 
the  exact  prevention  of  disease,  especially  of  commu- 
nicable diseases,  must  necessarily  now  fall  on 

the  epidemiologist, 

the  vital  statistician,  and 

the  laboratory  worker. 

Present  Limitations  of  Epidemiology 

The  epidemiologist  must  always  remain  the  chief  of 
these  three,  suggesting  and  arranging  the  details  ap- 
propriate to  each  investigation,  putting  together  the 
facts  supplied  by  the  two  other  workers  and  drawing 
legitimate  conclusions.  In  conducting  his  inquiries  and 
in  searching  for  further  light  on  obscure  points,  he  will 
need  to  remember  Simon's  remarks  (Eighth  Report  of 
the  Privy  Council) : 

In  the  category  of  time,  far  out  of  human  reach,  there  are 
circumstances  which  greatly  influence  contagion.  .  .  .  These 
almost  cosmic  arisings  are  spreadings  of  disease  or  facts  of 
cosmo-chemical  disturbance  which  no  mere  contagionism  can 
explain. 

These  words  had  special  reference  to  cholera,  and 
although  we  still  know  little  or  nothing  of  the  mysteri- 
ous influences  which  permit  cholera  when  unimpeded 
to  undertake  transmundane  travels  at  irregular  inter- 
vals of  time,  we  can  claim  with  certainty  that  in  any 
country  in  which  sanitary  surveillance  is  well  organ- 
ised, and  the  internal  sanitation  of  the  country  is  good, 


DURING   THE   LAST   FIFTY   YEARS  23 

the  spread  of  cholera  need  not  be  feared.  Thanks  to 
the  great  discovery  of  Jenner  and  to  the  complete 
organization  of  measures  for  isolation  of  the  sick,  and 
for  vaccination  and  surveillance  of  contacts,  we  can 
make  the  same  claim  for  smallpox,  whenever  this  mys- 
terious disease  begins  its  occasional  world  travels. 

But  we  have  to  confess  our  continuing  relative  help- 
lessness in  preventing  the  spread  of  measles,  and  of 
acute  catarrhs,  among  our  endemic  infections,  and  still 
more  of  influenza  when — as  recently — it  makes  its 
devastating  swoop  on  the  entire  world,  and  secures  a 
larger  number  of  victims  than  the  World  War  itself. 

We  can  recommend  isolation  of  the  sick,  and  personal 
precautions  in  speaking  and  in  coughing  and  sneezing, 
and  occasionally  may  score  an  isolated  success ;  but  we 
are  practically  helpless  against  this  enemy.  Nor  are 
we  better  acquainted  with  the  means  for  preventing 
the  spread  of  poliomyelitis ;  and  we  cannot  claim  that 
any  measure  against  the  spread  of  cerebro-spinal  fever 
has  had  undoubted  success,  except  only  rapid  ameliora- 
tion of  the  conditions  of  overcrowding  under  which  it 
especially  occurs.  These  instances  suffice  to  show  that 
in  the  region  of  respiratory  infections,: — with  the  one 
notable  exception  of  tuberculosis,  which  we  can  con- 
trol, whenever  we  are  ready  to  take  the  necessary  com- 
plete measures — we  have  much  to  learn.  In  respect 
of  most  diseases  due  to  respiratory  infection  we  are 
groping  in  darkness  nearly  as  dense  as  that  which 


24  PUBLIC    HEALTH    PROGRESS    IN    ENGLAND 

beset  Chadwick,  Farr  and  Simon  in  their  earlier  work, 
and  with  little  hope  of  any  campaign  comparable  with 
that  against  dirt  en  masse,  which  was  largely  effective 
in  reducing  the  specific  infections  of  cholera,  dysen- 
tery, and  enteric  fever,  of  typhus  fever  and  even  of 
tuberculosis. 

The  great  public  health  requirements  for  the  future 
are  the  conquest  over  acute  respiratory  infections,  in- 
cluding not  only  affections  of  the  lungs,  but  probably 
also  measles  and  whooping  cough,  cerebro-spinal  fever 
and  poliomyelitis  and  their  allies;  and  the  prevention 
of  cancer.  So  while  thankful  for  the  discoveries 
already  made,  and  for  the  beneficent  work  already 
accomplished,  we  must  hope  that  the  rapid  increase 
of  Medical  Research  in  England  and  here  will  in  due 
time  enable  us  to  extend  the  application  of  preventive 
medicine  to  diseases  so  far  uncontrollable. 

The  Importance  of  Vital  Statistics 
In  England  public  health  progress  has  been  largely 
actuated  by  records  of  mortality,  which  have  served 
to  make  the  public  realise  the  need  for  expenditure  of 
money  on  sanitary  reform.  Experience  has  shown,  as 
Dr.  J.  S.  Fulton  has  expressed  it,  that 

y  every  wheel  that  turns  in  the  service  of  public  health  must  be 
belted  to  the  shaft  of  vital  statistics. 

Accurate  and  complete  returns  of  deaths  and  their 
causes  are  essential  in  investigating  the  local  and  occu- 


DURING  THE   LAST   FIFTY   YEARS  25 

pational  incidence  of  disease,  and  in  comparing  the 
experience  of  different  communities:  and  the  various 
weekly,  quarterly,  annual,  and  decennial  reports  issued 
from  the  Registrar-General's  Department  have  ren- 
dered invaluable  service  to  the  cause  of  public  health. 
"Ye  shall  know  the  truth,  and  the  truth  shall  make 
you  free." 

It  was  not  the  least  of  Chadwick's  services  to  the 
State  that  he  discovered  William  Farr.  who  was  in- 
trusted with  the  compilation  of,  and  comment  on,  our 
early  statistics  from  1837  onwards.  His  reports,  with 
those  of  Simon,  embody  the  history  of  sanitary  prog- 
ress in  England  and  the  motives  and  arguments  which 
actuated  it. 

The  registration  of  births  similarly  enabled  com- 
parison of  birth-rates  to  be  made;  also  of  maternal 
mortality  in  child-bearing  and  of  infant  mortality  in 
different  areas,  and  at  different  parts  of  the  first  year 
of  life;  and  these  studies  made  by  medical  officers  of 
health  and  more  exhaustively  in  the  Medical  Depart- 
ment of  the  Local  Government  Board  have  had  great 
influence  in  determining  the  intensive  work  for  im- 
proving the  conditions  of  childbearing  and  of  infant 
rearing,  which  in  recent  years  has  been  accomplished. 

As  time  went  on  it  became  clear  that  registration  of 
deaths  gave  a  very  imperfect  view  of  the  prevalence 
of  disease,  and  that  so  far  as  infectious  diseases  were 
concerned,  valuable  time  was  lost  when  preventive 


26  PUBLIC    HEALTH    PROGRESS    IN    ENGLAND 

action  could  only  be  taken  after  the  patient's  death. 
Death  registration  told  of  the  total  wrecks  which  had 
occurred  during  the  storm ;  it  gave  no  information  as 
to  early  mishaps,  enabling  others  to  trim  their  vessels 
and  thus  weather  through.  It  gave  a  list  of  killed  in 
battle,  not  of  the  wounded  also. 

And  so  began  gradually,  in  characteristic  British 
fashion,  the  notification  of  infectious  cases,  the  list  of 
notifiable  diseases  being  extended  from  time  to  time. 

From  1911  onwards  the  Local  Government  Board 
prepared  a  weekly  statement  of  infectious  cases  noti- 
fied in  each  sanitary  area  which  was  distributed  to 
every  medical  officer  of  health.  Similar  returns  of 
exotic  diseases  of  interest  to  port  medical  officers  were 
distributed ;  and  the  successive  annual  summaries  pre- 
pared in  the  Medical  Department  of  the  Local  Govern- 
ment Board  showing  the  incidence  of  the  chief  epi- 
demic diseases  in  every  area  now  constitute  one  of  the 
most  valuable  epidemiological  records  extant. 

Collaterally  with  the  notification  of  infectious  dis- 
eases, including  tuberculosis,  to  the  medical  officer  of 
health,  occurred  the  enforcement  of  notification  of 
various  industrial  diseases  occurring  in  factories,  such 
as  anthrax,  lead  and  arsenic  poisoning,  to  the  Chief 
Inspector  of  Factories,  Home  Office. 


DURING   THE   LAST   FIFTY   YEARS  27 

Conditions  of  Medical  Practice  Bearing  on  Public 
Health 

^ 

It  cannot  be  claimed  that  notification  of  acute  infec- 
tious diseases,  still  less  of  tuberculosis,  has  been  com- 
plete. It  is  impossible  to  discuss  the  reasons  for  this 
in  the  present  address  (see  Lecture  IX)  ;  but  the  pres- 
ent conditions  of  medical  practice  are  largely  respon- 
sible for  the  partial  lack  of  success.  Hasty  conditions 
of  work,  failure  to  employ  laboratory  means  of  diag- 
nosis, or  to  utilise  available  consultation  facilities 
(especially  in  tuberculosis),  and  lack  of  training  of 
medical  practitioners  in  preventive  medicine,  are 
among  the  obstacles  to  further  control  of  disease. 

There  will  not  be  complete  success  until  means  are 
discovered  for  training  and  enlisting  every  medical 
practitioner  as  a  medical  officer  of  health  in  the  circle 
of  his  private  or  public  practice,  and  of  securing  his 
services  not  only  in  the  early  and  prompt  detection  of 
disease,  but  also  in  the  systematic  supervision  during 
health  of  the  families  under  his  care,  and  in  advising 
them  as  to  habits  or  methods  of  life  which  are  inimical 
to  health. 

Poor  Law  v.  Public  Health 

An  approximation  to  this  ideal  was  in  the  minds  of 
the  early  sanitary  reformers;  and  it  was  one  of  the 
misfortunes  associated  with  the  deterrent  policy  of 
poor-law  administration  in  medical  relief,  that  separa- 


28  PUBLIC    HEALTH    PROGRESS   IN   ENGLAND 

tion  between  Poor  Law  and  Public  Health  appeared  to 
offer  the  best  prospect  of  sanitary  progress. 

Had  Simon's  advice  been  followed,  when  the  Local 
Government  Board  was  about  to  take  over  the  public 
health  duties  of  the  Privy  Council,  the  poor-law  or- 
ganization might,  and  probably  would  gradually,  have 
been  permeated  by  public  health  activities,  and  thus 
the  sanitary  welfare  of  the  poorest  class  of  the  com- 
munity would  have  been  more  completely  safeguarded 
on  its  personal  as  well  as  on  its  environmental  side. 

In  his  Eleventh  Report  to  the  Privy  Council  (1868) 
Simon  recommended  adherence  to  the  intention  of  Mr. 
Lowe's  Nuisance  Bill  of  1860,  which  would  have  iden- 
tified the  health  and  destitution  authorities.  He  de- 
precated the  institution  of  "a  differently  planned 
organization  for  objects  exclusively  of  health  " ;  sub- 
ject to  the  conditions  that  public  health  should  not  be 
subordinate  to  poor-law  work  and  that  there  should 
be  power  to  combine  districts  for  certain  purposes, 
and  action  through  committees  in  sub-areas. 

Had  this  course  been  pursued,  and  had  the  central 
public  health  policy  not  been  preponderantly  non- 
medical  and  poor-law  in  sentiment  and  tradition,  more 
rapid  progress  in  public  health  would  have  been  expe- 
rienced. The  central  evil  was  intensified,  as  is  shown 
in  Simon's  Public  Health  Institutions,  by  regarding  the 
medical  officer  of  the  Local  Government  Board  as 
merely  advisory,  and  by  the  retention  and  extension 


DURING   THE   LAST   FIFTY   YEARS  29 

on  a  large  scale  of  local  inspection  by  lay  officers  of 
the  Central  Board,  for  conditions  which  needed  sys- 
tematic medical  control. 

The  problem  of  the  proper  relation  between  destitu- 
tion and  public  health  and  between  the  authorities 
dealing  with  these,  runs  right  through  our  past  history 
of  social  progress,  and  it  is  not  even  yet  satisfactorily 
adjusted. 

The  gradually  increasing  dissatisfaction  with  Poor 
Law  administration  led  to  the  appointment  of  a  Royal 
Commission  which  after  several  years  deliberation,  in 
1909  presented  a  Majority  and  a  Minority  Report. 

The  dissatisfaction,  which  these  reports  justified, 
may  be  said  to  have  been  inherent  in  the  situation ;  for 
the  Poor  Law  organization  was  constantly  attempt- 
ing,— more  or  less  under  the  influence  of  the  principle 
of  "  deterrence," — two  incompatible  tasks :  to  prevent 
undue  dependence  upon  parochial  assistance  and  to 
give  to  those  needing  them  the  medical  and  nursing 
assistance  which  the  principles  of  preventive  medicine 
require  should  be  given  unstintingly,  and  completely 
freed  from  any  deterrent  element.  Although  in  many 
parochial  areas  admirable  medical  work  was  done,  this 
was  the  exception,  not  the  rule;  and  public  sentiment 
rebelled  against  the  giving  or  the  receiving  of  medical 
assistance  to  which  was  attached  the  "poor-law  stigma." 
Both  reports  recommended  the  scrapping  of  the  poor- 
law  machinery  by  abolishing  the  present  Boards  of 


3O  PUBLIC    HEALTH    PROGRESS    IN    ENGLAND 

Guardians  and  the  general  mixed  workhouse ;  and  the 
Minority  Report  went  further,  proposing  to  complete 
the  supersession  of  the  poor-law  by  various  preventive 
authorities,  which  were  already  partially  in  operation. 
i/Thus  everything  connected  with  the  treatment  of  the 
sick  would  be  transferred  to  the  Public  Health  Au- 
thorities, the  care  of  school  children  to  Education  Au- 
thorities, of  lunacy  and  the  feeble-minded  to  already 
existing  Asylum  Committees,  and  so  on. 
y    Behind  these  proposals  lay  the  principle  that  the 
I/    treatment  and  the  prevention  of  disease  cannot  admin- 
istratively be  separated  without  injuring  the  possibili- 
ties of  success  of  both;  and  this  is  a  principle  which 
happily  is  becoming  more  generally  accepted. 

Before  the  report  of  the  Poor  Law  Commission  was 
issued,  examples  of  the  application  of  this  axiom  ex- 
isted in  the  isolation  and  treatment  of  patients  with 
acute  infectious  diseases;  in  the  increasing  provision 
for  the  treatment  of  tuberculosis ;  in  the  extension  of 
provision  for  care  of  parturient  women  and  for  their 
infants ;  and  in  the  system  of  school  medical  inspection 
followed  to  some  extent  by  treatment. 

It  is  convenient  to  add  here,  that  under  each  of  these 
headings,  great  extensions  have  been  made  since  1911 ; 
and  an  even  more  spectacular  public  provision  of  treat- 
ment, as  the  best  method  of  preventing  further  exten- 
sion of  disease,  is  exemplified  in  the  gratuitous  and 
confidential  diagnosis  by  laboratory  assistance  and 


DURING   THE   LAST   FIFTY   YEARS  3! 

the  treatment  of  venereal  diseases  now  given  in  every 
large  town  in  the  country,  the  Central  Government 
x>- paying  three  fourths  and  the  Local  Authority  one 
fourth  of  its  cost.  In  order  further  to  secure  the  suc- 
cess of  this  treatment, — which  is  provided  for  all 
comers  with  no  residential  or  financial  conditions, — the 
legislature  has  passed  an  enactment  forbidding  the 
advertisement  or  offering  for  sale  of  any  remedy  for 
these  diseases,  and  forbidding  their  treatment  except 
by  qualified  medical  practitioners. 

It  is  one  of  the  great  misfortunes  of  more  recent 
Public  Health  administration  that  the  Report  of  the 
Royal  Commission  on  the  Poor  Laws  has  not  hitherto 
been  made  the  subject  of  legislation.  It  would  not 
have  been  an  insuperable  task  to  find  a  common  meas- 
ure of  agreement  between  the  Majority  and  the  Mi- 
nority Reports.  Indeed  an  adjustment  has  recently 
been  made  between  these  two  reports,  as  the  result  of 
the  deliberations  of  a  House  of  Commons  Commit- 
tee, over  which  Sir  Donald  Maclean  presided;  and 
it  may  be  hoped  that  ere  long  this  will  mean  the  reali- 
sation of  a  much  belated  reform  of  local  adminis- 
tration. 

This  forms  an  indispensable  step  in  the  needed 
further  struggle  against  the  problems  of  Destitution. 
So  much  of  destitution  is  due  to  sickness  that  the  sepa- 
ration of  the  two  problems  is  inconsistent  with  success. 
"  One-third  of  all  the  paupers  are  sick,  one-third  chil- 


32  PUBLIC    HEALTH    PROGRESS   IN    ENGLAND 

dren,  and  one-quarter  either  widows  encumbered  by 
young  families  or  certified  lunatics."  There  are  eco- 
nomic causes  of  poverty,  apart  from  sickness,  but  it  is 
essential  to  remember  that  every  disease  which  is  con- 
trolled frees  the  community  not  only  from  a  measur- 
able amount  of  sickness,  but  from  the  amount  of  pov- 
erty implied  by  this  sickness. 

Had  the  policy  of  transfer  of  the  duties  of  Poor 
Law  authorities  to  the  Councils  of  Counties  and 
County  Boroughs  recommended  in  1909  by  the  Poor 
Law  Commission  been  adopted,  these  last  named  au- 
thorities would  already  possess  a  medical  service  for 
the  poor  employing  some  4,000  doctors ;  they  would  be 
in  possession  of  the  large  infirmaries  and  other  medical 
institutions  of  the  poor  law,  and  given  reforms  and 
readjustments  of  these  which  are  urgently  required, 
and  combination  of  the  hospital  arrangements  of  poor- 
law  and  public  health,  would  have  a  greatly  improved 
medical  service  freed  from  poor-law  shackles  and  capa- 
ble of  gradual  extension  as  needs  and  policy  indicate. 
The  fusion  of  these  two  services  with  the  school  med- 
ical service  would  have  been  an  easy  further  step; 
and  England  would  by  this  time  have  built  up  a  Na- 
tional Medical  Service,  for  the  very  poor,  for  all  pur- 
poses of  public  health — including  poor-law — admin- 
istration, and  for  children  and  their  mothers  in  special 
circumstances. 


DURING   THE   LAST   FIFTY   YEARS  33 

Insurance  v.  Public  Health 

Political  circumstances,  into  which  it  is  unnecessary 
to  enter,  led  to  the  adoption  of  a  course,  which  medi- 
cally ran  directly  athwart  the  course  of  needed  reform. 
The  National  (Health)  Insurance  Act,  1911,  was 
passed,  giving  sickness  and  invalidity  benefits  to  those 
employed  persons  below  a  certain  income  who  could 
contribute  a  weekly  sum,  which  was  considerably  less 
than  half  the  estimated  cost  of  the  benefits  to  be  re- 
ceived; and  an  additional  medical  service,  further 
complicating  the  already  existing  medical  services  of 
the  poor  law,  public  health,  and  educational  authori- 
ties, was  set  up. 

The  establishment  of  national  insurance  against  sick- 
ness and  disablement  in  the  United  Kingdom  exem- 
plifies the  contagiousness,  under  modern  conditions  of 
life,  of  a  new  course  adopted  in  any  country ;  and  Bis- 
marck's attempt  to  counteract  socialism  by  insurance 
has  been  responsible  for  international,  state  and  official 
experimentation  in  insurance  which  has  not  generally 
been  well  advised,  and  which  is  associated  in  England 
with  extravagant  cost  of  administration. 

Insurance  against  sickness  is  a  praiseworthy  and 
valuable  provision  against  future  contingencies;  and 
on  its  non-medical  side  free  from  drawbacks.  Neither 
on  its  medical  nor  on  its  non-medical  side,  however,  is 
it  an  alternative  to  prevention  of  disease ;  and  the  Na- 
tional Insurance  Act  in  England  must  be  held  in  the 
4 


34  PUBLIC   HEALTH   PROGRESS   IN   ENGLAND 

main  to  have  delayed  the  public  health  reform  which 
would  have  been  secured  had  equal  effort  been  devoted 
to  it,  and  the  money  lavished  on  insurance  given  in  the 
form  of  central  public  health  grants  conditional  on  the 
active  cooperation  of  local  authorities.J  True,  the 
English  public  have  been  educated  to  think  in  regard 
to  sickness  in  millions  when  previous  provisions  for 
the  treatment  and  prevention  of  sickness  had  been 
thought  of  in  thousands  of  pounds ;  and  there  has  been 
an  extension  of  provision  for  the  institutional  treat- 
ment of  tuberculosis,  which  probably  has  been  more 
rapid  than  would  otherwise  have  been  made,  in  the 
absence  of  the  alternative  grants  named  above.  It 
should  be  added  that,  owing  to  the  natural  insistence 
of  insured  tuberculous  patients  on  treatment  in  a  sana- 
torum,  and  to  the  desire  of  Local  Insurance  Com- 
mittees and  their  officers  to  satisfy  insured  persons, 
sanatoria  have  often  been  filled  with  unsuitable  pa- 
tients, sent  there  regardless  of  relative  social  and 
public  health  needs.  The  Maternity  Benefit  (of  a 
sum  of  money  on  the  birth  of  an  infant  to  the  wife 
of  an  insured  person  or  to  an  employed  woman)  simi- 
larly is  given  unconditionally,  and  should  be  replaced 
or  supplemented  by  the  provision  of  service  needed  at 
this  time  (doctor  or  mid-wife,  nurse,  domestic  assist- 
ance) ,  which  would  ensure  the  welfare  of  both  mother 
and  infant. 

Apart  from  other  reforms  the  transfer  of  medical 
provision,  of  provision  for  tuberculous  patients,  and 


DURING   THE   LAST   FIFTY   YEARS  35 

for  parturient  women  to  public  health  authorities  is 
urgently  needed;  and  the  service  should  be  given  ac- 
cording to  need  irrespective  of  insurance.  The  valua- 
ble fund  for  medical  research  has  already  been  placed 
under  the  Privy  Council. 

The  absurdity  of  regarding  insurance  as  anything 
beyond  a  possibly  useful  handmaiden  and  auxiliary  to 
Public  Health,  when  strict  administrative  arrange- 
ments are  made  for  this  purpose,  may  be  illustrated  by 
the  question  as  to  what  would  have  been  the  result  in 
sanitary  progress  if  Chadwick  or  Simon  had  persuaded 
the  government  of  their  day  to  insure  a  favoured  sec- 
tion of  the  public  against  the  risk  of  typhus  or  small- 
pox or  tuberculosis  or  even  of  non-infectious  illness? 

Under  the  National  Insurance  Act  medical  domi- 
ciliary assistance, — but  only  to  the  extent  which  is 
within  the  competence  of  a  medical  practitioner  of 
average  ability, — is  provided  under  contract  for  one- 
third  of  the  total  population;  and  evidently  this  im- 
plies an  immense  abstraction  from  ordinary  private 
medical  practice.  There  is  no  provision,  hitherto,  for 
consultant  and  expert  facilities  when  required  (except 
for  tuberculosis),  for  the  nursing  of  patients,  or  for 
institutional  treatment  of  any  disease,  except  tubercu- 
losis ;  and  no  funds  are  generally  available  for  these 
purposes  except  such  as  belong  to  the  community  at 
large. 

In  view  of  the  preceding  facts  and  of  other  consid- 


36  PUBLIC   HEALTH    PROGRESS   IN   ENGLAND 

erations  which  I  have  not  mentioned,  reconstruction 
of  the  English  Insurance  scheme  is  obviously  required. 
The  scheme  cannot  persist  in  its  present  form.  The 
already  accomplished  amalgamation  of  the  Local  Gov- 
ernment Board  and  National  Insurance  Commission, 
should  make  radical  changes  easier ;  an  equally  impor- 
tant step  would  be  the  transfer  of  the  medical  func- 
tions of  the  Local  Insurance  Committees  to  Public 
Health  Authorities.  The  creation  of  these  independ- 
ent committees  was  one  of  the  greatest  blunders  of 
the  National  Insurance  Act,  which  was  conceived  ill- 
advisedly,  had  too  short  a  gestation,  and  suffered  a 
premature  and  forced  delivery ;  and  we  may  hope  that 
ere  long,  it  may  be  replaced  entirely,  on  its  medical  and 
hygienic  side,  by  a  rapid  extension  of  the  medical  ac- 
tivities of  the  public  health  service  which  will  conduce 
to  the  welfare  of  the  whole  nation. 

It  is  impossible  to  justify  the  continuance  of  state 
subsidisation  of  benefits  for  a  favoured  portion  of  the 
wage-earning  classes,  when  poorer  persons  who  do  not 
come  within  the  category  of  employed  persons  or  who 
fall  out  of  employment,  and  when  clerks  and  others 
on  limited  salaries  who  are  unable  to  provide  ade- 
quately for  sickness,  are  left  unprovided  for. 

A  National  Medical  Service 

What  is  most  urgently  needed  is  a  national  medical 
service  which  will  give  for  all  who  cannot  afford  them 


DURING  THE   LAST   FIFTY   YEARS  37 

hospital  treatment  and  the  services  of  consultants  and 
of  scientific  aids  to  diagnosis  and  treatment  whenever 
required ;  and  which  will  provide  nurses  during  illness 
treated  at  home,  when  this  is  asked  for  by  the  doctor 
in  attendance. 

Outside  the  operation  of  the  National  Insurance 
Act,  these  services  have  been  provided  to  a  steadily 
increasing  extent,  but  in  a  characteristically  British 
fashion.  They  have  grown  largely  under  voluntary 
management,  and  as  exemplifications  of  Christian  phi- 
lanthropy; though  official  has  rapidly  overtaken  the 
voluntary  provision  of  hospitals  and  nursing,  the  two 
working  side  by  side,  each  in  their  respective  spheres, 
and  on  the  whole  with  cordial  cooperation.  The  ex- 
tent to  which  institutional  treatment  with  its  more 
satisfactory  arrangements  is  replacing  the  domiciliary 
treatment  of  disease  may  be  gathered  from  the  follow- 
ing striking  facts : 

In  England  and  Wales 

Of  deaths  from  all  causes,  in  1881  =  i  in  every  9 
Of  deaths  from  all  causes,  in  1910=1  in  every  5 

In  London 

Of  deaths  from  all  causes,  in  1881  =  I  in  every  5 
Of  deaths  from  all  causes,  in  1910  =  2  in  every  5 

occurred  in  public  institutions. 

The  facts  as  to  Pulmonary  Tuberculosis  are  even 
more  significant: 
In  the  year  191 1 


38  PUBLIC    HEALTH    PROGRESS   IN   ENGLAND 

in  England  and  Wales  34%  of  male  22%  of  female 
and  in  London       59%  of  male  and  48%  of  female 

deaths  from  pulmonary  tuberculosis  occurred  in  public 
institutions ;  and  as  each  of  these  patients  spent  on  an 
average  several  months  in  hospital,  at  the  most  infec- 
tious stage  of  their  illness,  a  material  annual  reduction 
in  the  possibility  of  massive  infection  of  relatives  and 
others  has  been  secured. 

is  Hospitals  Important  Housing  Auxiliaries 
This  institutional  treatment  of  the  sick  has  been 
one  of  the  chief  influences  counteracting  the  perni- 
cious effects  of  industrialism  and  urbanization.  It  has 
relieved  housing  difficulties  at  a  time  when  insufficient 
bedroom  accommodation  is  most  injurious ;  and  it  has 
secured  year  by  year  for  a  steadily  increasing  propor- 
tion of  the  total  population  the  improvements  of  mod- 
ern surgery  and  medicine  as  practised  in  institutions, 
which  permit  of  the  poor  thus  treated  receiving  more 
satisfactory  and  more  hopeful  treatment  than  is  ob- 
tainable for  a  large  proportion  of  other  classes  of 
society. 

My  address  is  already  too  long.  Other  opportu- 
nities will  be  taken  of  explaining  the  rapidly  increas- 
ing part  which  the  State  and  Public  Health  Authori- 
ties are  taking  in  the  hygiene  and  care  of  motherhood 
and  childhood  and  of  school  children ;  in  the  provision 
of  additional  nursing  services  for  the  sick,  in  the 


DURING  THE   LAST   FIFTY   YEARS  39 

rapid  growth  in  numbers  of  public  health  nurses, 
health  visitors,  school  nurses,  etc. ;  in  special  schemes 
for  the  treatment  of  tuberculosis  and  of  venereal  dis- 
eases ;  and  the  circumstances  under  which  the  Central 
Government  are  to  a  rapidly  increasing  extent  paying 
half  (or  in  certain  instances  three-fourths)  of  ap- 
proved local  expenditure  on  the  provision  of  hygienic, 
nursing  and  medical  services;  and  I  do  not  therefore 
dwell  on  these  points  further. 

Nor  need  I  comment  here  on  the  remarkable  fact 
that  the  British  Government  under  present  circum- 
stances have  departed  from  the  economic  position  that 
houses  built  by  local  authorities  must  be  able  to  be  let 
at  a  rental  covering  all  outgoings. 

In  Lecture  II  I  shall  deal  with  problems  of  local 
and  central  government,  and  with  the  training  and 
appointment  of  medical  officers  of  health;  but  the 
present  review,  if  it  omitted  from  consideration  on  the 
one  hand  the  value  of  specially  trained  whole-time 
health  officers,  and  on  the  other  hand  the  health  sig- 
nificance of  the  general  advance  in  the  standard  of 
medical  treatment,  as  factors  of  prime  importance  in 
securing  the  already  achieved  improvement  in  human 
life  and  health,  would  give  a  most  imperfect  picture 
of  the  actual  facts. 


4O  PUBLIC    HEALTH    PROGRESS    IN    ENGLAND 

The  need  to  avoid  Complacency 
Such  figures  as  I  have  given,  showing  saving  and 
prolongation  of  life  during  the  last  fifty  years,  are  apt, 
if  left  uncorrected,  to  create  a  complacent  warmth 
tending  to  public  health  inertia.  It  may  conduce 
further  to  this  folding  of  the  hands  when  I  state  that 
Simon  in  his  first  report  to  the  Local  Government 
Board  expressed  the  opinion  that  the  half  million 
deaths  a  year  approximately  which  occurred  in  1871 
in  England  and  Wales  were  a  third  (125,000)  more 
numerous  than  they  would  be  if  existing  knowledge 
of  the  chief  causes  of  disease  were  reasonably  well 
applied  throughout  the  country ;  and  further  that  had 
the  mortality  experience  during  1911-15  held  good  for 
1871,  the  deaths  in  that  year  would  have  been  reduced 
by  200,000  instead  of  by  125,000,  the  ideal  then  aimed 
at  by  Simon. 

But  with  increased  knowledge  we  know  that  a  larger 
proportion  of  diseases  are  preventable  than  was  for- 
merly supposed.  It  will  be  easy  within  the  next  ten 
years  to  reduce  the  death-rate  by  one-third  of  its 
present  amount,  given  systematic  and  adequate  ac- 
f  tion  on  the  part  of  Public  Health  Authorities  and  an 
effective  educational  propaganda  among  the  general 
public.  More  important  still,  an  even  larger  propor- 
tion of  mankind's  total  illness  can  be  avoided,  and  life 
on  a  higher  plane  of  health  secured,  as  well  as  life 
prolonged  to  its  normal  limit.  The  work  carried  out 


DURING   THE   LAST   FIFTY   YEARS  41 

during  the  last  ten  years,  sanitary,  medical  and  hy- 
gienic, in  improving  the  prospects  of  healthy  child- 
bearing  and  of  normal  infancy  and  childhood  consti- 
tute the  most  important  advance  toward  national  phys- 
iological life  on  a  higher  plane  which  has  hitherto  been 
made. 

Preventive  medicine  can  never  be  satisfied  until  it 
has  approached  Isaiah's  ideal  (Isaiah,  LXV,  20), 
"  There  shall  be  no  more  thence  an  infant  of  days,  nor 
an  old  man  that  hath  not  filled  his  days ;  for  the  child 
shall  die  a  hundred  years  old." 


CHAPTER  II 

THE  HISTORICAL  DEVELOPMENT  OF  PUBLIC  HEALTH 
POLICY  IN  ENGLAND1 

The  subject  is  too  large  to  be  treated  adequately  in 
the  course  of  an  evening's  address;  and  to  bring  it 
within  manageable  compass  it  is  necessary  for  me  to 
select  my  material  rigidly  and,  as  far  as  I  can,  to  pre- 
sent this  material  in  such  a  manner  as  will  bring  into 
relief  its  salient  and  most  instructive  features. 

The  evolution  of  public  health  in  England  proceeded 
by  experimental  steps,  some  mistaken  and  then  re- 
traced, others  mistaken  and  not  retraced,  but  steps 
oftenest  in  the  direction  of  a  complete  service,  which 
is  the  goal  of  our  work. 

The  evolution  has  been  a  gradual  growth  arising 
out  of  realized  needs,  rather  than  a  logical  develop- 
ment based  on  general  principles;  and  as  politicians 
and  legislators  seldom  take  a  wide  outlook,  or  con- 
sider a  specific  proposal  in  relation  to  what  is  already 
being  done,  and  to  what  is  the  desired  goal,  the  Eng- 
lish experience  is  especially  instructive. 

1  An  Address  at  the  Forty-seventh  Annual  Meeting  of  the 
American  Public  Health  Association,  New  Orleans,  October 
27,  1919. 

42 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  43 

Town-living  and  Health  Problems 
Public  health  work  became  an  urgent  necessity 
when  men  began  to  huddle  in  towns;  and  with  the 
industrial  revolution  of  the  eighteenth  and  early  nine- 
teenth centuries  the  need  for  remedial  action  became 
acute.  It  is  hard  to  realize  that  in  the  days  of  our 
grandfathers,  the  home  was  in  most  instances  the  unit 
of  industry;  and  that  in  the  eighteenth  century  com- 
munications between  districts  and  towns  were  not 
more  advanced  than  those  of  the  ancient  Egyptians. 
When,  however,  vast  urban  aggregations  of  popula- 
tion multiplied,  travelling  facilities  rapidly  increased, 
and  the  results  of  crowding,  of  contaminated  water 
supplies,  of  intensive  and  widespread  infection,  were 
seen  in  devastating  endemic  and  epidemic  diseases. 
Poverty,  squalor,  dirt,  and  their  consequences,  were 
rampant  in  the  towns,  where  underpaid  work-people 
were  exploited  by  masters,  whose  self-centred  outlook 
had  some  share  of  justification  in  the  political  economy 
doctrines  of  the  time,  which  regarded  any  interference 
with  "  freedom  of  contract "  as  useless  or  even 
pernicious. 

What  is  public  health  work?  It  is  best  defined  by 
stating  its  object,  which  is  to  secure  the  maximum  at- 
tainable health  of  every  member  of  the  community,  so 
far  as  this  can  be  secured  by  the  authorities,  local, 
state,  or  federal,  concerned  in  any  part  of  government, 
acting  in  cooperation  with  all  voluntary  agencies  whose 


v/i 


44  THE    HISTORICAL   DEVELOPMENT  OF 

work  conduces  to  the  same  end.  The  connotation  of 
public  health  becomes  wider  year  by  year.  It  em- 
braces physiological  as  well  as  pathological  life;  being 
as  much  concerned  with  improving  the  standard  of 
health  of  each  person  as  with  the  prevention  and  cure 
of  disease.  Hence  the  importance  of  the  "  concentra- 
tion on  the  mother  and  her  child"  (John  Burns),  to 
secure  for  them  by  all  practicable  means  the  conditions 
of  complete  health,  which  during  the  last  twelve  years 
has  been  a  vital  part  of  our  public  health  work,  and 
.which  is  now  being  made  to  include  not  only  all  hy- 
gienic and  medical  help  that  may  be  needed,  but  also 
such  domestic  aid  as  may  enable  the  mother  to  bring 
her  children  into  the  world  and  to  rear  them  under 
advantageous  conditions. 

Scope  of  Constructive  Health  Work 
Public  health  embraces  some  eugenic  elements,  and 
may  comprise  more  when  eugenists  have  accumulated 
adequate  non-fallacious  evidence  on  which  to  base 
valid  conclusions.  Already  partial  steps  are  being 
taken  to  secure  the  segregation  and  prevent  the  propa- 
gation of  the  feeble-minded  and  the  insane;  and  in 
sorting  out  congenital  infection  from  true  heredity 
action  is  being  taken  to  avoid  congenital  syphilis  and 
to  prevent  the  large  number  of  still-births  due  to  this 
race  poison. 

Public  health  in  the  main  is  concerned  primarily. 


PUBLIC    HEALTH    POLICY    IN    ENGLAND  45 

with  the  environmental  measures  calculated  to  prevent 
the  attack  of  man  by  disease,  whether  pre-natal  or 
post-natal.  These  measures  may  be  industrial,  as  in 
the  prevention  of  accidents,  of  dust,  of  noxious  va- 
pours ;  or  sanitary,  as  in  the  control  of  water  supplies, 
food,  or  milk,  and  in  the  removal  of  organic  filth ;  or 
may  be  the  application  of  preventive  medicine  against 
infectious  and  non-infectious  diseases ;  or  therapeutic, 
consisting  of  the  prompt  and  adequate  treatment  of 
all  illnesses  and  the  curtailment  of  the  incompetence 
due  to  them ;  or  educational,  consisting,  first  in  impor- 
tance, in  the  training  of  medical  practitioners,  of  pub- 
lic health  officials,  and  nurses;  and,  next,  in  the  edu- 
cation of  the  general  public  and  especially  of  the  chil- 
dren in  our  schools,  in  the  science  and  practice  of  pub- 
lic health. 

Advances  in  public  health  in  many  directions  can 
only  be  secured  by  continued  and  extended  medical 
research,  and  public  health,  therefore,  has  a  direct  and 
immediate  interest  in  promoting  and  subsidizing  such 
research. 

These  being  the  objects  of  public  health,  how  far 
'•-  have  we  travelled  toward  securing  the  end  in  view  ? 
I  do  not  propose  to  myself  the  pleasant  task  of  show- 
ing to  what  extent  the  general  death-rate  has  been 
lowered,  infant  and  child  mortality  greatly  reduced, 
the  duration  of  life  extended,  how  typhus  and  small- 
pox have  been  almost  eradicated,  typhoid  fever  made 


46  THE    HISTORICAL   DEVELOPMENT   OF 

a  disappearing  disease,  and  tuberculosis  has  become 
the  cause  of  only  half  its  former  death  rate.  When 
inclined  to  indulge  in  such  pleasant  considerations,  I 
recall  the  statement  I  have  made  elsewhere  that  one- 
half  of  the  mortality  and  disablement  still  occurring 
at  ages  below  seventy  can  be  obviated  by  the  applica- 
tion of  medical  knowledge  already  within  our  posses- 
sion. 

Let  me  attempt  the  more  difficult  task  of  outlining 
the  history  of  forms  of  administrative  control  of  dis- 
ease since  1834. 

•  Reform  in  the  Control  of  Poverty 
Poverty  and  disease  work  in  a  vicious  circle  in  which 
cause  and  effect  often  change  places ;  but  it  is  certain 
that  disease  is  one  of  the  most  fertile  causes  of  pov- 
erty, using  the  word  poverty  in  the  sense  of  privation 
of  one  or  other  essential  of  physical  well  being. 

For  this  reason,  and  because  the  half  starved  form 
a  constant  social  danger,  poor-law  administration  long 
antedated  public  health  administration.  There  is  not 
time  to  follow  the  course  of  earlier  poor-law  admin- 
istration, with  its  many  and  grievous  abuses.  The 
Poor-Law  Amendment  Act  of  1834,  gave  the  Central 
Government  control  over  the  systems  of  local  relief, 
secured  the  combination  of  parishes  into  unions  for 
poor-law  relief,2  and  forbade  outdoor  relief  to  able- 

2  The  importance  of  this  is  seen  in  the  fact  that  there  are  in 
England  and  Wales  14,614  parishes,  and  only  646  unions  for 
the  relief  of  the  poor. 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  47 

bodied  men.  The  creation  of  an  organ  of  central  con- 
trol has  led  to  the  subsequent  course  of  aid  to  paupers 
being  determined  in  the  main  in  London,  action  of 
poor-law  guardians  being  subject  to  supervision  by 
government  inspectors,  and  to  endorsement  by  the 
Central  Authority.  At  first,  medical  assistance  under 
the  reformed  Poor  Law  was  made  as  deterrent  as  non- 
medical  relief ;  and  although  there  has  been  much  im- 
provement, chiefly  on  the  institutional  side,  medical 
treatment  under  the  Poor  Law  has  to  some  extent  re- 
tained this  deterrent  element,  and  it  has,  except  in 
the  poor-law  infirmaries  of  large  cities,  remained  gen- 
erally disliked  by  the  people  concerned. 

The  first  Central  Poor-Law  Authority  was  a  Com- 
mission having  no  representative  in  Parliament.  In 
1847  it  was  replaced  by  a  Board,  the  president  of  which 
was  a  member  of  Parliament  and  of  the  Government. 
Here  once  for  all  Parliament  declared  its  intention  to 
maintain  direct  control  of  central  official  government, 
and  in  this  and  in  all  other  departments  has  done  so. 
If  democracy  is  to  be  real, — and  we  have  no  sound, 
practicable  alternative  to  it,— evidently  the  representa- 
tives of  the  people  must  be  masters  of  the  administra- 
tion; and  English  policy  has  never  wavered  on  this 
point.  After  many  years'  experience  of  public  life  in 
England,  I  have  no  hesitation  in  saying  that  this  prin- 
ciple is  sound ;  that  it  insures  progress  which,  although 
slow,  is  less  liable  to  relapse  than  administration  under 


48  THE   HISTORICAL  DEVELOPMENT  OF 

autonomous  expert  commissions,  whether  centrally  or 
locally;  and  that  any  lack  of  progress  that  has  been 
experienced  in  central  government  has  been  as  much 
the  result  of  inactivity  and  of  lack  of  sympathy  with 
social  reform  on  the  part  of  the  permanent  officials  of 
government  departments  who  have  had  access  to  their 
parliamentary  chief,  as  of  the  inertia  of  politicians  or 
their  obstruction  to  reform. 

Dissatisfaction  with  Poor-L.aw  administration  has 
steadily  increased  in  the  years  since  1834,  as  the  prob- 
lem of  the  able-bodied  pauper  has  diminished  and  the 
Poor  Law  has  been  concerned  more  and  more  with  the 
sick  and  infirm,  the  aged,  and  children.  These  at  the 
present  time  form  some  98  per  cent,  of  the  total  popu- 
lation relieved.  The  fundamental  principles  of  the 
Poor  Law  were  rightly  attacked.  It  did  not  comprise 
elements  tending  to  build  up  disabled  families,  or  to 
prevent  families  from  falling  hopelessly  and  perma- 
nently into  destitution.  The  law  was  administered 
almost  entirely  with  a  view  to  relief;  practically  not 
at  all  as  a  curative  agency.  In  medical  language, 
symptomatic  and  not  rational  causal  treatment  was  the 
rule. 

In  medical  relief,  poor-law  administration  has  been 
a  constant  struggle  between  increasingly  humane  treat- 
ment and  the  conception  that  the  pauper's  position 
must  remain  inferior  to  that  of  the  non-pauper;  an 
important  principle  when  applied  to  the  able-bodied 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  49 

adult  who  has  drifted  into  willing  dependence;  mis- 
chievous when  applied  to  sick  persons,  and  to  depend- 
ent women  and  children. 

The  general  dissatisfaction  with  poor-law  adminis- 
tration led  to  the  appointment  of  a  Royal  Commission 
on  the  Poor-Laws  which,  after  several  years'  delib- 
eration, published  in  1909  a  majority  and  a  minority 
report.  Both  these  reports  recommended  the  aboli- 
tion of  boards  of  guardians,  and  the  transfer  of  their 
duties  to  the  144  largest  public  health  authorities  in 
the  country  (County  Councils,  44;  and  the  Councils  of 
county  boroughs,  82),  and  the  abolition  of  the  general 
workhouse.  The  majority  report  would  have  continued 
the  Poor-Law  Guardians  as  a  Committee  of  the  new 
Authority;  the  minority  report  proposed  to  distribute 
the  duties  of  the  guardians  to  different  committees  of 
the  Public  Health  Authority;  thus  medical  treatment 
to  the  Public  Health  Committee;  the  care  of  lunacy 
and  the  feebleminded  to  the  Asylum  Committee ;  care 
of  children  to  the  Education  Committee;  vagrants, 
etc.,  to  the  Police  Committee ;  a  special  committee  con- 
cerning itself  with  all  questions  of  monetary  assistance. 

A  compromise  between  these  two  schemes  has  re- 
cently been  arranged,  and  when  the  new  Ministry  of 
Health,  which  will  combine  public  health,  poor-law, 
insurance,  and  educational  medical  work  in  one  de- 
partment, has  found  time  to  do  urgently  needed  work, 
the  above  indicated  reform  may  be  hoped  for,  along 

5 


5O  THE    HISTORICAL   DEVELOPMENT  OF 

with  the  even  more  urgently  needed  reform  of  local 
public  health  administration,  and  the  abolition  of  a 
large  number  of  the  smaller  and  less  efficient  sanitary 
authorities.  With  these  reforms  will  come  much 
needed  de-centralization  of  poor-law  work.  Good 
work  in  all  respects  cannot  be  secured  if  the  Central 
Authority  concerns  itself,  as  at  present,  in  minutiae  of 
local  administration,  and  has  no  time  to  devote  itself 
to  the  larger  problems,  and  to  the  task  of  bringing 
indifferent,  chiefly  smaller  authorities,  up  to  the  stand- 
ard of  efficient  local  authorities.  A  large  portion  of 
the  expense  of  local  poor-law  administration  is  borne 
by  the  central  exchequer,  and  this  money  if  properly 
applied  will  give  the  necessary  leverage  for  reform, 
while  leaving  progressive  Authorities,  and  especially 
the  Authorities  of  large  towns,  free  to  experiment  and 
advance. 

Reform  in  Industry 

The  industrial  revolution  meant  the  subjection  of 
large  masses  of  working  class  families  to  evil  condi- 
tions of  housing  and  work  in  crowded  and  insanitary 
dwellings  and  factories.  The  public  conscience  first 
rebelled  in  regard  to  boarded  out  and  apprentised 
pauper  children ;  and  the  first  Factory  Act  in  1802  con- 
cerned itself  with  them;  and  with  this  Act  emerged 
the  germ  of  machinery  for  securing  compliance  with 
the  law,  magistrates  and  clergymen  being  appointed 
as  inspectors  under  the  Act. 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  51 

The  Act  was  largely  futile ;  but  it  meant  the  begin- 
ning of  the  gradual  breaking  down  of  laissez  faire 
doctrines ;  and  there  followed  a  more  widely  operative 
Factory  Act  in  1833,  restricting  hours  of  labor  of 
children,  and  initiating  professional  inspectors  con- 
trolled and  paid  by  the  Government.  In  1842  the 
underground  employment  of  women  in  mines  was 
forbidden;  and  at  intervals  since  then  numerous  fac- 
tory and  allied  acts  have  been  passed,  restricting  the 
duration  and  conditions  of  work  of  women  and  chil- 
dren, improving  rules  as  to  sanitation,  insuring  syste- 
matic inspection  by  government  inspectors,  and  con- 
stituting a  far  reaching  system  of  supervision  and 
control. 

The  inspectors,  on  whom  falls  the  burden  of  ensur- 
ing compliance  with  the  Factory  Laws  and  regulations 
made  under  them,  are  controlled  by  the  department  of 
the  central  government  known  as  the  Home  Office; 
their  work  on  the  whole  has  been  well  done,  and  the 
conditions  of  factory  and  workshop  life  have  greatly 
improved.  Some  portion  of  the  sanitary  supervision 
of  these  work-places  falls  on  the  local  Sanitary  Au- 
thority ;  but  in  the  main  the  system  is  one  of  absolutely 
centralized  government  control.  This  secures  almost 
complete  absence  of  improper  influence  of  interested 
local  persons,  whether  masters  or  workmen;  but  it  is 
arguable  that  this  system  should  be  replaced  by  a  local- 
ized system,  the  inspectors  being  officers  of  the  144 


52  THE   HISTORICAL  DEVELOPMENT  OF 

larger  authorities.  These  local  officers  could  be  placed 
in  direct  touch  with  the  Home  Office  or  the  Ministry  of 
Health  and  with  the  central  staff  of  inspectors  having 
expert  knowledge  in  the  different  branches  of  indus- 
trial work. 

Public  Health  Reform 

Public  health  reform  was  a  direct  consequence  of 
the  Poor-Law  Amendment  Act,  1834.  Anxious  to  di- 
minish the  enormous  expense  of  the  existing  Poor 
Law,  and  realizing  that  a  large  share  of  this  sickness 
was  due  to  fever  and  other  illnesses,  surveys  and  in- 
quiries were  set  on  foot  by  the  commissioners  admin- 
istering this  Act,  and  the  reports  which  followed  re- 
vealed a  state  of  things  urgently  calling  for  sanitary 
reform,  in  the  interest  of  national  economy  as  well  as 
of  health.  "An  Act  for  Promoting  the  Public  Health" 
was  passed  in  August,  1848,  which  created  a  General 
Board  of  Health  consisting  of  four  members  and  a 
secretary.  These  Commissioners,  among  whom  was 
Edwin  Chadwick,  former  Secretary  of  the  Poor  Law 
Board,  initiated  a  system  of  procedure  which  was 
largely  on  the  lines  of  poor-law  action,  and  which  in- 
volved constant  pin-pricking  by  the  Central  Authority 
of  the  grossly  indifferent  local  authorities.  The  com- 
missioners were  more  zealous  than  discreet ;  and  after 
six  years  they  were  no  longer  tolerated.  At  that  time 
centralization  was  as  much  a  bogie  as  socialism  has 
become  in  more  recent  years.  Parliament  and  the  lo- 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  53 

calities  represented  by  its  members  doubtless  feared 
the  reforming  activity  of  Chadwick  and  his  colleagues, 
though  they  sheltered  themselves  behind  their  exag- 
gerated fears  of  bureaucracy  and  centralization. 

A  new  board  replaced  the  old,  parliamentary  in  char- 
acter, its  president  being  a  member  of  the  Government. 
This  repeated,  so  far  as  concerns  Parliamentary  head- 
ship, the  story  of  the  Poor-Law  Board,  and  estab- 
lished once  more  the  theory  of  the  administrative 
control  of  the  representatives  of  the  people.  Nor,  al- 
though the  change  meant  for  the  time  serious  slacken- 
ing in  sanitary  reform,  can  objection  be  taken  to  it. 
In  a  democratic  government  the  elected  representatives 
of  the  people  must  take  first  place;  and  it  is  the  role 
of  officials  to  educate  them  in  the  direction  of  needed 
reforms.  Reforms  which  do  not  carry  public  opinion 
with  them  are  not  likely  to  be  permanently  successful ; 
and,  whether  in  administration  or  in  legislation,  at- 
tempts to  sidetrack  or  ignore  this  fact  are  not  likely 
to  be  permanently  effective. 

Public  Health  Reforms 

When  the  Local  Government  Board  was  formed  in 
1870,  a  second  opportunity  was  IOJ}L  of  developing 
Public  Health  Administration  on  lines  which  we  now 
know  to  be  the  best  adapted  for  a  complete  service  of 
preventive  medicine.  The  first  lost  opportunity  was 
when  sanitary  authorities,  completely  separate  from 


54  THE    HISTORICAL   DEVELOPMENT  OF 

poor-law  authorities,  were  created  for  administering 
the  sanitary  laws.  Probably  this  arose  from  Chad- 
wick's  despair  of  getting  effective  sanitary  reform 
from  poor-law  guardians ;  but  the  creation  of  separate 
authorities  was  scarcely  consistent  with  the  fact  recog- 
nized by  him  that  pauperism  is  largely,  if  not  pre- 
dominantly a  question  of  sickness ;  or  with  the  less 
recognized  fact  that  its  treatment  forms  an  essential 
part  of  prevention.  It  was  recognized  that  the  care  of 
the  sick  was  largely  idle  until  the  unnecessary  causes 
of  disease  had  been  cut  off,  but  not  that  the  adequate 
treatment  of  sickness  is  an  important  means  of  pre- 
venting it  or  of  curtailing  it.  Rumsey,3in  1856,  stated 
the  unrealized  possibilities  of  the  poor-law  medical 
officer's  domiciliary  attendance  on  paupers  in  the  fol- 
lowing words : 

There  are  much  higher  functions  of  a  preventive  nature 
than  those  of  a  mere  "  public  informer "  which  the  district 
medical  officer  ought  to  perform.  He  should  become  the  sani- 
tary adviser  of  the  poor  in  their  dwellings  ...  he  (should) 
be  in  a  peculiar  sense,  the  missionary  of  health  in  his  own 
parish  or  district, — instructing  the  working  classes  in  personal 
and  domestic  hygiene, — and  practically  proving  to  the  helpless 
and  debased,  the  disheartened  and  disaffected,  that  the  State 
cares  for  them,  a  fact  of  which,  until  of  late,  they  have  seen 
but  little  evidence. 

In  the  result  the  ad  hoc  poor-law  authority  did  not 
absorb  into  it  the  newly  created  municipal  and  urban 

8  Rumsey :  Essays  in  State  Medicine,  1856,  pp.  190,  277,  282. 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  55 

and  rural  sanitary  administration,  but  continued  on  its 
separate  path. 

Simon,  in  1868,  had  urged  the  inadvisability  of  con- 
tinuing ad  hoc  authorities,  and  had  urged  that,  at  least, 
sanitary  should  be  made  coterminous  in  area  of  ad- 
ministration with  poor-law  districts.  His  advice  was 
not  adopted,  and  there  followed  years  in  which  sani- 
tary authorities  were  allowed  to  subdivide  areas,  until 
the  total  number  became  1,807  instead  of  635,  the 
number  of  poor-law  authorities;  and  in  which  they 
concerned  themselves  chiefly  with  nuisances  and  water 
supplies  and  with  inadequate  provision  for  the  preven- 
tion and  treatment  of  infectious  diseases.  With  the 
creation  of  county  councils  and  the  more  complete  au- 
tonomy of  the  councils  of  county  boroughs,  the  large 
centres  of  population  developed  and  improved  their 
sanitary  administration  more  rapidly;  and  it  became 
practicable  to  undertake  every  division  of  sanitary 
work  on  an  efficient  scale.  Although  much  remains 
to  be  done,  it  can  be  claimed  that  in  our  larger  towns, 
containing  more  than  half  of  the  total  population  of 
the  country,  the  public  health  work  in  nearly  all  its 
branches  is  of  a  high  order.  It  would  have  been  still 
more  efficient  had  the  poor-law  guardians  been  merged 
in  the  Town  Council,  and  had  the  relationship  between 
the  school  medical  service  and  the  other  branches  of  the 
public  health  service  been  closer  than  has  been  the  case. 

What  is  now  needed  is  that  the  defects  just  named 


56  THE    HISTORICAL   DEVELOPMENT  OF 

should  be  made  good;  that  more  complete  autonomy 
should  be  given  to  the  authorities  which  come  up  to  a 
required  standard,  and  that  especially  they  should  have 
greater  freedom  in  developing  local  possibilities  of 
improved  administration.  Central  grants  in  aid  of 
local  sanitary  administration  are  steadily  increasing. 
Already  the  Government  pays  one-half  of  local  ex- 
penditure on  a  large  program  of  maternity  and  child 
welfare  work,  one-half  of  the  expense  of  local  tuber- 
culosis work,  and  three-fourths  of  the  expense  of  local 
work  for  the  diagnosis  and  treatment  of  venereal  dis- 
eases, and  for  propaganda  work  concerning  these. 
These  grants  should  be  the  means  of  greatly  increas- 
ing good  local  administration ;  but  if, — this  is  improba- 
ble,— they  curtail  local  experimentation  and  extension, 
and  bring  local  public  health  administration  into  any- 
thing approaching  the  subservience  of  local  poor-law 
administration,  the  value  of  these  subventions  will  be 
doubtful. 

Education  Authorities  and  Health 

The  national  system  of  compulsory  elementary  edu- 
cation inaugurated  in  1870  has  had  valuable  indirect 
influence  in  promoting  the  public  health.  Apart  from 
the  beneficent  effect  of  education,  the  steadily  increas- 
ing pressure  on  children  to  come  to  school  in  a  cleanly 
condition  and  the  stimulus  of  emulation  in  tidiness  and 
cleanliness,  have  done  much  to  improve  the  home  con- 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  57 

ditions  of  the  people.  After  the  South  African  war 
much  attention  was  drawn  to  the  large  number  of  re- 
cruits rejected  owing  to  physical  disabilities;  and  an 
inter-departmental  committee  reported  inter  alia  in 
favour  of  a  system  of  medical  inspection  of  pupils  in 
elementary  schools,  which  had  often  been  urged  by 
hygienists.  Observations  made  in  Glasgow  and  Edin- 
burgh by  Leslie  Mackenzie  did  much  to  draw  attention 
to  the  physical  defects  in  Scottish  school  children.  In 
1907  the  Board  of  Education  acquired  power  to  make 
provision  through  the  local  education  authorities  for 
the  medical  inspection  and  treatment  of  school  chil- 
dren. At  first  little  more  than  inspection  of  pupils 
was  undertaken,  a  large  number  of  defects  of  sight, 
hearing,  parasitic  conditions,  as  well  as  malnutrition 
and  actual  disease  being  discovered.  Gradually  some 
items  of  treatment  were  undertaken  at  school  clinics, 
or  at  hospitals  or  centres  subsidized  by  the  education 
authorities;  though  the  amount  of  treatment  is  still 
small  compared  to  the  defects  discovered  and  not 
otherwise  treated. 

But  there  now  existed  in  every  locality  three  au- 
thorities concerned  in  the  treatment  of  disease : 

1.  Poor-law  guardians,  treating  all  forms  of  illness 
in  paupers,  at  home  and  in  institutions. 

2.  Public  health  authorities,  undertaking  preventive 
measures  against  disease,  and  treating  fevers,  tuber- 
culosis, and  occasionally  other  diseases  in  institutions ; 


*8  THE    HISTORICAL   DEVELOPMENT   OF 

**  •      -.    ;    .  -r« 

and  more  recently  providing  nurses  at  home  for  cer- 
tain conditions. 

3.  Local  education  authorities,  concerned  in  treat- 
ing certain  ailments  in  school  children. 

Centrally  two  government  departments  were  super- 
vising this  work,  and  subsidizing  it  to  some  extent 
from  government  funds;  and  poor-law  medical  work 
and  public  health  medical  work  were  supervised  by 
two  divisions  of  the  Local  Government  Board  acting 
in  almost  complete  isolation.  More  recently  Parlia- 
ment has  permitted  the  Board  of  Education  to  give 
grants  in  aid  of  schools  for  mothers,  and  allied  insti- 
tutions for  the  care  of  children  under  school  age ;  for 
which  institutions,  substantially,  the  Local  Govern- 
ment Board  in  other  instances  was  giving  grants. 

The  separation  of  the  medical  work  of  Education 
Authorities  from  public  health  medical  work  was  con- 
trary to  the  first  principles  of  sound  administration; 
although  it  is  possible  that,  owing  to  the  inertia  in  some 
public  health  circles,  this  separation  at  first  favored 
rapid  advance  in  school  hygiene;  just  as  the  early 
development  of  public  health  apart  from  poor-law 
administration  was  probably  more  rapid  than  could 
have  been  expected  from  centrally  ridden  local  authori- 
ties, concerned  chiefly  in  keeping  down  the  poor  rates. 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  59 

The  AdHoc  Vice 

But  in  both  instances  there  was  an  offence  against 
the  first  principles  of  good  administration,  which  re- 
quire that  when  a  special  function  is  to  be  undertaken 
it  shall  be  undertaken  by  one  governing  body  for  the 
whole  community  needing  the  service,  and  not  for  dif- 
ferent sections  of  the  community  by  several  governing 
bodies.  Medical  treatment  is  needed  for  school  chil- 
dren and  for  the  poor  generally.  Why  separate  this 
into  two  administrations?  Hospitals  are  required  for 
paupers  with  tuberculosis,  and  for  non-paupers  with 
tuberculosis.  Why  have  two  authorities  for  this 
work?  The  separate  existence  of  Education  and 
Poor-Law  Authorities  qua  medical  attendance  on  those 
children  needing  it  erred,  not  only  in  this  fundamental 
respect,  but  also  because  neither  of  these  authorities 
had  the  preventive  facilities  and  powers  possessed  by 
Public  Health  Authorities,  who  were  also  partially 
engaged  in  the  treatment  of  disease. 

The  inveterate  tendency  in  the  past  has  been  to 
create  a  new  authority  when  any  new  work  was  in- 
augurated, this  authority  then  fulfilling  all  purposes 
for  a  special  portion  of  the  community  and  thus  nec- 
essarily duplicating  the  staffs  of  other  departments  of 
local  or  central  government.  The  crowning  instance 
of  this  recurring  instance  of  legislative  myopia  is  seen 
in  the  case  of  the  National  Insurance  Act,  under  which 
has  been  provided  an  imperfect  and  unsatisfactory 


6O  THE    HISTORICAL   DEVELOPMENT   OF 

domiciliary  medical  service  for  one-third  of  the  entire 
population  of  Great  Britain,  when  by  combining  and 
extending  the  medical  forces  of  existing  departments 
of  the  state,  a  satisfactory  service  for  all  needing  it 
would  have  been  secured.  The  axiom  that  "the  ob- 
ject of  community  service  is  to  do  away  with  group 
competitions  and  bring  in  its  place  group  cooperation 
or  team  work"  (Goodnow),  is  especially  applicable 
to  all  public  health  and  medical  work ;  and  the  spirit  of 
this  axiom  is  infringed  by  the  existence  of  separate, 
sometimes  competing,  occasionally  conflicting,  services 
under  separate  local  and  central  control. 

Principles  of  Local  Government 
The  preceding  considerations  bear  on  the  perennial 
problem  of  efficient  government,  local  and  central. 
There  are  three  functions  to  be  performed  in  govern- 
ment, legislation,  determination  of  administrative  pol- 
icy and  extent  of  work,  and  the  actual  executive  work. 

,^*J*.  *«wmwMWiwaMiM>MW*"*w*»*^'**  «^"***^»»«»t«i»^«rt*»M*>ll— *  ^"    1 

In  England,  legislation  is  in  the  hands  of  Parliament 
and  is  usually  national  in  scope.  Large  cities,  how- 
ever, not  infrequently  obtain  special  legislative  power 
to  meet  local  needs ;  and  by  this  means  have  succeeded 
in  advancing  local  efficiency  above  the  average  stand- 
ard. Local  authorities,  furthermore,  have  the  power 
to  make  regulations  and  by-laws  for  special  purposes, 
subject  to  the  approval  of  the  Central  Authority. 
In  settling  the  details  of  local  administration,  the 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  6 1 

elected  representatives  of  the  public  are  supreme. 
They  meet  in  Council,  and  action  is  taken  on  a  major- 
ity vote.  The  councils  of  counties  and  cities,  and  even 
of  smaller  municipal  boroughs  divide  themselves  into 
committees,  each  consisting  of  about  a  dozen  mem- 
bers, elected  by  vote  of  the  whole  Council.  The  chair- 
man or  mayor  of  the  Council  has  no  special  power, 
except  that  he  may  give  a  casting  vote. 

The  chief  defect  in  local  sanitary  administration  in 
England  is  the  continued  existence  of  a  large  number 
of  small  and  relatively  inefficient  local  authorities. 
The  larger  authorities,  as  a  rule,  do  their  work  well, 
and  politics  enter  but  little  into  elections.  Official 
posts  are  not  vacated  with  changing  councils.  These 
councils  are  approximating  to  the  ideal  of  a  complete 
local  Parliament  dealing  with  all  governmental  con- 
cerns, and  to  the  further  ideal  that  each  unit  of  govern- 
ment should  be  large  enough  to  minimize  the  influence 
of  local  interested  motives,  and  to  undertake  each  de- 
partment of  municipal  work  on  a  considerable  scale. 
The  local  Parliament  has  committees  concerned  with 
police,  finance,  public  health,  education ;  and  when  the 
urgently  needed  poor-law  reforms  are  made,  and 
when  the  Education  Committee  hands  over  its  medical 
work  to  the  Public  Health  Committee,  the  ideal  will 
become  a  fact. 

Power  is  already  given  to  coopt  on  to  some  of  these 
committees  a  few  persons  who  are  not  members  of 


62  THE    HISTORICAL   DEVELOPMENT   OF 

the  Council,  from  among  men  or  women  having  spe- 
cial knowledge  of  the  Committee's  work ;  and  the  ex- 
ercise of  this  power  has  been  found  to  be  useful. 

But  in  each  committee  it  is  the  direct  representatives 
of  the  public  who  decide  points  of  policy  and  settle  the 
main  outlines  of  administration.  There  is  growing  up 
a  tendency  to  appoint  local  advisory  committees,  con- 
sisting of  special  groups  representing  professional  or 
trade  interests.  Thus  a  medical  committee  may  be 
consulted  on  medical  proposals,  and  so  on.  This  is 
still  in  the  experimental  stage.  It  will  probably  prove 
permanently  useful,  as  voicing  the  occupational  aspect 
of  any  proposed  work  of  the  municipality ;  but  it  will 
need  to  be  kept  to  its  strictly  consultative  limitations, 
and  the  responsibility  of  the  Council  as  representing 
the  combined  wisdom  or  unwisdom  of  the  entire  com- 
munity must  be  maintained. 

All  substitutes  for  government  of  the  people  by  the 
representatives  of  the  whole  population  are  open  to 
objection.  They  do  not  contain  within  them  the  ele- 
ments of  permanence.  If  there  is  a  corrupt  council, 
the  remedy  is  not  its  supersession  by  an  independent 
executive.  Such  an  executive  is  the  abrogation  of 
popular  government.  "  Good  and  efficient  govern- 
ment is  possible  under  almost  any  form  of  organiza- 
tion. More  depends  upon  men  than  devices.  .  .  .  But 
...  if  we  believe  that  the  functions  of  deliberation 
or  determination  of  municipal  policy  and  of  adminis- 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  63 

tration  or  the  execution  or  carrying  out  of  that  policy 
should  be  kept  distinct,  we  cannot  avoid  the  conclusion 
that  a  city  council  is  a  necessary  part  of  the  municipal 
organization."* 

Each  committee  of  the  local  Council  is  advised  by 
the  County  Clerk  or  Town  Clerk  on  legal  and  admin- 
istrative matters ;  and  the  medical  officer  of  health  and 
other  expert  officers,  like  the  legal  adviser,  in  nearly 
every  instance,  hold  office  during  good  behaviour. 
Under  the  above  arrangements  the  elected  members 
and  the  officials  are  kept  in  touch  with  each  other. 
The  latter's  recommendations  and  actual  work  must 
be  approved  by  the  former ;  and  this  works  well  under 
the  system  of  determination  of  policy  by  committees, 
subject  to  confirmation  and  control  by  the  entire  Coun- 
cil. The  motive  power  is  public  opinion.  Good  work 
cannot  for  any  prolonged  period  go  beyond  what  the 
public  demand,  and  the  work  of  officials  is  one  of  con- 
stant education  of  their  masters  and  of  the  public. 

The  Training  and  Tenure  of  Office  of  Health 
Officers 

Every  sanitary  district  is  required  to  appoint  a  med- 
ical officer  of  health  and  since  1888  every  medical 
officer  of  health  for  a  district  with  a  population  ex- 
ceeding 50,000  must  have  a  special  diploma  in  public 
health.  The  enforcement  of  this  requirement  has 

4  Goodnow :  Municipal  Problems,  p.  226. 


64  THE   HISTORICAL  DEVELOPMENT  OF 

done  much  to  raise  the  standard  of  work  of  these 
officers.  It  is  significant,  furthermore,  that  while  in 
1873  the  percentage  of  the  total  population  of  England 
and  Wales  having  whole-time  medical  officers  of 
health  was  only  20.6,  it  had  increased  to  61 .4  per  cent, 
in  1911.  In  the  metropolis,  in  the  whole  of  Scotland, 
in  every  English  county  (forty-four)  and  in  many 
other  districts  these  officers  possess  security  of  tenure, 
in  the  sense  that  they  cannot  be  removed  from  office 
without  the  consent  of  the  Central  Government,  which 
usually  pays  half  their  salaries.  Even  without  this 
safeguard,  removal  from  office  by  the  local  authority 
is  rare ;  but  there  has  been  long  delay  in  securing  the 
further  reform  that  in  all  areas  the  medical  officer  of 
health  should  be  able  to  perform  his  difficult  and  some- 
times obnoxious  duties  without  fear  of  removal  from 
office,  or  of  reduction  in  his  emolument,  except  as  the 
result  of  deliberate  action  on  appeal  to  a  central  au- 
thority. 

When  pensions  can  be  earned  by  medical  officers 
of  health  and  by  all  medical  men  on  the  public  health 
staff,  their  position  will  become  more  attractive  for 
men  of  good  standing;  and  this  reform  has  become 
more  important  in  view  of  the  steadily  increasing  com- 
plexity of  the  medical  work  now  undertaken  in  a  large 
public  health  department.  It  will  include  inter  alia 
the  following  officers  and  activities:  superintendent 
medical  officers  of  health;  district  medical  officers  of 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  65 

health ;  tuberculosis  officers ;  medical  officers  of  mater- 
nity and  child  welfare  centres,  of  venereal  disease 
centres;  fever  hospitals,  and  tuberculosis  sanatoriums 
and  hospitals. 

The  development  of  a  graduated  public  health  med- 
ical service  in  which  each  physician  employed  will  be 
able  to  develop  his  own  special  abilities,  will  be  easier 
when  to  the  above  list  is  added  the  work  of  district 
(late  Poor-La w)  medical  officers;  medical  practition- 
ers attending  insured  persons  and  such  other  persons 
as  are  treated  at  the  expense  of  the  State;  treatment 
centres  for  special  conditions  of  the  ear,  eye,  throat; 
gynecological  and  other  special  departments;  hospital 
treatment  for  general  diseases. 

That  there  will  be  development  in  these  directions 
when  the  tangle  caused  by  the  National  Insurance  Act 
of  1911  has  been  unravelled,  there  can  be  no  doubt. 

I  have  in  Lecture  IV  expressed  my  opinion  as  to 
the  additional  tangle  introduced  into  the  central  and 
local  government  of  the  United  Kingdom  by  the  Na- 
tional Insurance  Act  of  1911. 

The  failure  of  the  British  Government  to  act  on  the 
recommendations  of  the  Poor-Law  Commission  of 
1909  was  a  serious  misfortune  to  public  health.  Sick- 
ness is  the  cause  of  a  predominant  part  of  our  total 
destitution,  and  to  allow  the  continued  separation  of 
administrative  action  respecting  these  two  problems  is 
inconsistent  with  a  full  measure  of  success.  Political 
6 


66  THE    HISTORICAL   DEVELOPMENT   OF 

circumstances,  however,  led  to  the  adoption  of  a  course 
which,  medically,  ran  directly  athwart  the  course  of 
needed  reform. 

i  The  National  Insurance  Act  and  Public  Health 

The  National  Insurance  Act  was  passed,  placing 
one-third  of  the  total  population  (all  employed  manual 
workers  and  other  employed  workers  with  an  income 
below  £160,  since  increased  to  £250)  under  an  obliga- 
tion to  pay  4d  weekly  (women  3d),  3d  being  contrib- 
uted for  each  person  by  the  employer  and  2d  by  the 
State.  In  return  each  worker  receives  a  money  pay- 
ment weekly  during  disability  from  illness,  attendance 
by  a  doctor,  sanatorium  treatment  for  tuberculosis,  and 
a  maternity  benefit  on  the  birth  of  a  child  to  his  wife 
(30  shillings),  or,  if  the  wife  also  is  industrially  em- 
ployed, an  additional  30  shillings.  The  medical  benefit 
is  limited  to  such  domiciliary  attendance  as  a  medical 
practitioner  of  average  ability  can  furnish.  It  con- 
tinues the  old  popular  conception  of  private  medical 
practice,  and  allows  the  public  to  remain  obsessed  with 
the  notion  that  satisfactory  medical  care  consists  in  a 
"  visit  and  a  bottle."  No  provision  is  made  for  patho- 
logical aids  to  diagnosis,  beyond  what  is  already  pro- 
vided by  public  health  authorities.  No  nurses  are 
available  for  serious  cases;  the  insured  person  is  not 
entitled  to  surgical  operations,  when  needed,  except  of 
the  simplest  character.  With  few  exceptions,  no  ap- 


PUBLIC   HEALTH   POLICY   IN   ENGLAND  67 

pliances  are  provided ;  the  treatment  of  special  diseases 
of  the  eye,  ear,  nose  and  teeth  is  commonly  excluded. 
No  hospital  provision  whatever,  except  for  tubercu- 
losis, is  made. 

The  contract  system  of  medical  practice  has  been 
accompanied  by  a  serious  amount  of  lax  certification 
of  sickness.  The  sanatorium  benefit  is  unnecessary, 
as  soon  as  the  duty  of  public  authorities  to  provide 
treatment  for  tuberculosis  is  declared  obligatory.  It 
is  already  very  largely  provided.  The  maternity  ben- 
efit is  entirely  unconditional;  there  is  no  guarantee 
that  it  is  devoted  to  the  welfare  of  the  mother  and 
infant.  It  needs  to  be  supplemented  or  replaced  by 
the  arrangements  for  providing  nurses,  doctors,  mid- 
wives,  and  domestic  assistance  which  are  in  process  of 
development  by  public  health  authorities.  In  short, 
there  is  no  justification  for  providing  medical  services, 
preponderantly  at  the  expense  of  the  state  (contribu- 
tions by  employers  are  a  form  of  taxation),  which  are 
limited  to  a  favored  portion  of  the  total  population, 
and  which  do  not  benefit  all  in  need  of  these  services. 

Provision  for  Sickness 

The  principle  of  monetary  insurance  against  sick- 
ness and  disability  is  thoroughly  sound.  It  forms  a 
praiseworthy  and  valuable  provision  against  future 
contingencies.  Insurance,  however,  is  not  synony- 
mous with  prevention  as  is  too  often  suggested.  In 


68  THE   HISTORICAL  DEVELOPMENT  OF 

England  insurance  has  been  an  actual  impediment  to 
public  health  work,  though  it  might  have  gradually 
become  a  useful  auxiliary  to  it  if  otherwise  organized, 
and  especially  if  the  creation  of  independent  insurance 
committees  representing  interests  to  a  preponderant 
extent  had  been  avoided.  But  any  medical  service 
needed  for  purposes  of  insurance  should  not  form  part 
of  the  insurance  system.  Medical  aid  is  needed  for  a 
large  section  of  the  population  who  are  unable  to  af- 
ford deductions  from  their  wages,  or  who  have  no 
wages.  It  is  needed  for  wives  and  children  as  much 
as  for  the  industrially  employed  head  of  the  house- 
hold; and  it  is  needed  for  many  others  who  are  ex- 
cluded from  the  scope  of  the  National  Insurance  Act. 
Only  when  the  medical  is  separated  from  the  insurance 
service,  and  when  the  medical  practitioner,  as  far  as 
practicable,  is  made  independent  of  the  patient  who 
desires  too  facile  a  sick-certificate,  will  good  medical 
work  and  sound  sickness  insurance  be  secured. 

General  Summary 

The  preceding  review  of  the  history  of  public  health 
in  England  is  necessarily  fragmentary.  It  does  not 
include,  for  instance,  a  discussion  of  the  relationship 
of  the  medical  profession  to  public  health  authorities. 
On  this  I  content  myself  with  repeating  my  oft  stated 
opinion  that  until  every  medical  practitioner  is  trained 
to  investigate  each  case  of  illness  from  a  preventive 


PUBLIC    HEALTH    POLICY   IN    ENGLAND  69 

as  well  as  from  what  is  often  rather  a  pharmaceutical 
than  a  really  curative  standpoint,  until  a  communal 
system  of  consultant  and  hospital  services  independ- 
ent of  any  insurance  system  is  made  available  for  all 
needing  it,  and  until  every  medical  practitioner  is  re- 
lated by  financial  and  official  ties  to  this  communal 
system,  full  control  over  disease, — to  the  extent  of  our 
present  available  medical  knowledge, — will  not  be 
secured. 

The  communal  system  will  include  not  only  the  pro- 
vision of  domiciliary  nurses  for  all  needing  them,  but 
also  a  greatly  increased  staff  of  public  health  nurses 
engaged  in  educational  supervision  in  connection  with 
the  work  of  the  communal  services  and  of  each  indi- 
vidual practitioner.  Such  a  system  will  repay  the 
community  manifold  in  improved  health  and  in  a 
higher  standard  of  happiness  and  well  being. 

If  objection  is  taken  to  such  wide  sweeping  propo- 
sals, let  me  remind  you  that  free  communal  services  of 
sanitation  and  education  are  already  provided;  and 
that  the  care  of  personal  health  is  of  equal  importance 
with  these.  All  will  agree  that  a  large  proportion  of 
the  population  cannot  afford  to  pay  individually  for 
medical  attendance  and  nursing  under  present  condi- 
tions, still  less  for  the  consultant  and  hospital  services 
which  advances  in  medical  service  have  rendered  in- 
dispensable. There  is  always  present  in  our  midst  a 
large  mass  of  illness  which  might  have  been  avoided 


7O  THE   HISTORICAL  DEVELOPMENT  OF 

or  curtailed,  had  there  been  an  organized  system  of 
state  medicine. 

Lest  there  should  be  alarm  as  to  the  possible  conse- 
quences of  the  cooperative  provision  on  such  a  scale 
of  this  primary  need  of  humanity,  let  me  also  remind 
you  that  cooperative  medical  aid  differs  from  financial 
1  aid  in  an  essential  particular.  It  does  not  create  a  de- 
mand for  further  aid,  but  is  always  engaged  in  di- 
\,  minishing  this  demand.  Dependency  on  financial 
assistance  is  liable  to  continue  indefinitely ;  much  wants 
more.  This  result  of  medical  aid  is  almost  inconceiv- 
able. The  Reverend  Doctor  Chalmers,  of  Glasgow, 
said  early  in  the  last  century:  "Ostensible  provision 
for  the  relief  of  poverty  creates  more  poverty.  An 
ostensible  provision  for  the  relief  of  disease  does  not 
create  more  disease." 

Doctor  Chalmers  was  opposed  to  the  giving  of  any 
domiciliary  assistance  from  rates  or  taxes,  and  he 
organized  his  parish  so  that  every  needy  person  was 
adequately  helped  out  of  charitable  funds.  But  he 
advocated  extended  hospital  and  other  medical  assist- 
ance for  the  poor;  and  until  this  is  done,  apart  alto- 
gether from  any  system  of  insurance,  and  as  a  com- 
plete measure  on  the  lines  of  our  educational  system, 
we  cannot  say  that  all  that  is  practicable  has  been  done 
to  secure  the  physical  well  being  of  our  fellow  citizens. 


CHAPTER  III 

THE  INCREASING  SOCIALIZATION  OF  MEDICINE  * 

Medicine  has  always  been  the  most  altruistic  of 
learned  professions;  and  can  proudly  claim  that  its 
practitioners  have  ever  been  ready  to  give  gratuitous 
assistance  to  all  in  need  of  it.  Even  more  than  when 
Burton  wrote  his  Anatomy  of  Melancholy — for  then 
medicine  was  an  art  with  but  limited  foundation  in  sci- 
ence— physicians  can  be  defined  as  "God's  interme- 
diate ministers " ;  and  can  rightly  assume  the  proud 
position  which  Burton  gives  them : 

Next,  therefore,  to  God,  in  all  our  extremities  (for  of  the 
Most  High  cometh  healing,  Eccles.  XXXVIII,  2)  we  must 
seek  to,  and  rely  upon,  the  Physician,  who  is  the  Manus  Dei 
(the  Hand  of  God),  said  Hierophilus,  and  to  whom  He  hath 
given  knowledge,  that  he  might  be  glorified  in  his  wondrous 
works. 

Each  medical  practitioner  in  his  own  circle,  and  to 
the  extent  of  his  medical  competence,  is  a  medical  offi- 
cer of  health,  having  more  influence  in  directing  and 
controlling  the  habits,  occupation,  the  housing,  the 
social  customs,  the  dietary  and  general  mode  of  life  of 
the  families  to  which  he  has  access,  than  any  other 

1  The  Wesley  M.  Carpenter  lecture  delivered  October  2, 
1919,  before  the  New  York  Academy  of  Medicine. 

71 


72     THE   INCREASING   SOCIALIZATION    OF    MEDICINE 

person.  It  must  be  added  that  in  most  instances  he 
has  even  more  influence  than  the  minister  of  religion 
in  regulating  the  ethical  conduct  of  his  patients,  espe- 
cially as  regards  alcoholism  and  sexual  vices.  In  the 
'  United  States  the  federal  government  has  relieved  the 
medical  profession  from  their  duty  of  restricting  indi- 
vidual alcoholic  consumption,  and  an  experiment  has 
been  begun  which  if  continued — and  I  trust  nothing 
will  prevent  this — must  forthwith  reduce  the  income  of 
practising  physicians  throughout  the  American  conti- 
nent, and  at  the  same  time  do  more  to  diminish  crime, 
accidents  and  sickness  and  to  increase  national  effi- 
ciency than  any  other  single  step  that  could  be  taken, 
with  one  exception.  This  would  consist  in  the  uni- 
versal raising  of  the  standard  of  sexual  conduct  of 
men  to  that  which  they  expect  from  their  future  wives, 
thus  securing  a  rapid  reduction  and  early  disappear- 
ance of  gonorrhoea  and  syphilis,  diseases  which  rank 
with  pneumonia,  tuberculosis  and  cancer  as  chief 
among  the  captains  of  death  and  disablement  in  our 
midst. 

The  growing  possibilities  of  improvement  in  per- 
sonal and  social  welfare  depend  very  largely  on  the 
extent  to  which,  as  I  have  put  it  elsewhere,  "each 
practitioner  becomes  a  medical  officer  of  health  in  the 
range  of  his  own  practice."  Even  on  their  present 
record,  if — at  least  on  one  side — the  Kingdom  of  God 
consists  in  "the  union  of  all  who  love  in  the  service 


THE   INCREASING  SOCIALIZATION   OF   MEDICINE     73 

of  all  who  suffer,"  medical  men  can  proudly  and  yet 
humbly  take  their  place  as  essential  agents  in  the  daily 
fulfilment  of  the  daily  prayer,  "  Thy  Kingdom  come." 

It  is  perhaps  desirable  to  attempt  at  this  stage  a  defi- 
nition of  the  sense  in  which  I  employ  the  term  sociali- 
zation of  medicine.  In  it  I  would  include  the  render- 
ing available  for  every  member  of  the  community, 
irrespective  of  any  necessary  relation  to  the  ordinary 
conditions  of  individual  payment,  of  all  the  potentialities 
of  preventive  and  curative  medicine.  Within  the  scope 
of  medicine  are  included  the  basic  sciences  of  physiol- 
ogy and  pathology;  and  the  instruction  and  training  of 
every  child  and  young  person  in  elementary  hygiene, 
including  dietetics,  necessarily  come  also  within  the 
range  of  our  subject. 

There  are  still  agnostics,  usually  of  exclusively  clas- 
sical and  mathematical  education,  even  among  men 
holding  official  sanitary  administrative  positions,  who 
doubt  the  value  of  the  application  of  medical  knowl- 
edge to  the  extent  indicated ;  and  it  becomes  desirable, 
therefore,  briefly  to  refer  to  some  results  already 
obtained  by  the  application  of  preventive  and  curative 
medicine. 

The  Past  Achievements  of  Medicine 

The  increasing  span  of  life  is  scarcely  realized  as  it 
should  be.  Addison's  description  of  the  bridge  of 
human  life,  in  his  Vision  of  Mirza,  is  familiar.  Its 


74     THE   INCREASING  SOCIALIZATION   OF   MEDICINE 

seventy  to  a  hundred  arches  support  a  bridge  which  is 
interrupted  by  broken  arches  and  hidden  pitfalls,  set 
very  thick  at  the  entrance  of  the  bridge,  thinner  to- 
wards its  middle,  but  multiplied  and  laid  close  together 
towards  its  further  end.  Preventive  medicine  is  grad- 
ually repairing  the  broken  arches  of  earlier  life ;  with 
the  prospect  of  rapid  reduction  of  tuberculosis,  of 
syphilis  and  gonorrhoea,  the  removal  of  pitfalls  and 
the  repair  of  both  earlier  and  middle  arches  are  en- 
sured, if  the  knowledge  we  already  possess  is  applied ; 
and  although  pneumonia  and  cancer  still  erode  and 
render  unsafe  the  arches  of  middle  and  later  adult  life, 
we  have  already  advanced  far  towards  the  ideal  of 
euthanasia  in  old  age. 

I  may  be  excused  from  quoting  English  figures,  as 
our  vital  statistics  are  more  accurate  and  complete 
than  those  hitherto  available  for  the  United  States. 
Parenthetically,  may  I  say  that  it  is  a  continual  source 
of  astonishment  to  me  that  in  some  American  states 
death  statistics,  and  in  many  more  states  birth  statistics 
should  still  be  so  dubious  in  their  quality  as  to  cause 
hesitation  in  utilizing  them.  And  this  in  a  country 
which  in  other  respects  combines  the  highest  business 
qualities  with  an  underlying  idealism  which  emerges  in 
important  crises ! 

Between  1871-80  and  1910-12  in  England  the  aver- 
age expectation  of  life  at  birth  for  males  increased 
from  41.4  to  51.5,  for  females  from  44.6  to  55.4, — an 


THE   INCREASING  SOCIALIZATION   OF   MEDICINE     75 

increase  within  three  or  four  decades  of  10  or  n 
years  in  average  duration  of  life.  The  annual  saving 
of  life  shown  by  these  figures  means  that  the  persons 
whose  lives  each  year  are  thus  saved  in  England  from 
premature  death,  have  the  prospect  of  living  in  the 
aggregate  nearly  ten  million  additional  years  of  life, 
of  which  the  greater  part  will  be  lived  during  the 
working  period  of  life. 

But  perhaps  more  striking  than  collective  statistics 
are  the  illustrations  of  unnecessary  premature  mortal- 
ity with  which  history  and  literature  in  the  Georgian 
and  Victorian  period  supply  us.  Many  such  instances 
will  occur  to  you.  William  Pitt  died  at  the  age  of 
47,  Charles  James  Fox  at  57.  The  history  of  the 
Bronte  family,  given  the  clue  that  tuberculosis  was  at 
work,  can  be  seen  on  the  tablet  which  I  have  often 
read  in  Haworth  Church.  Each  sister  and  the  brother 
died  in  steady  succession  at  intervals  of  two  and  three 
years;  the  only  exception  being  Charlotte,  who  had 
lived  much  away  from  home,  and  who  died  at  the  age 
of  39  of  unrestrained  vomiting,  a  condition  which 
probably  would  not  have  been  allowed  to  kill  the  ex- 
pectant mother  today.  Robert  Burns  died  at  the  age 
of  37,  Keats  at  the  age  of  26.  Lord  Byron  on  his 
thirty-third  birthday,  only  three  years  before  his  death, 
wrote  as  a  man  already  "  in  the  sere  and  yellow  leaf  " 

Along  life's  road,  so  dim  and  dirty, 
I've  travelled  till  I'm  three  and  thirty; 


76     THE   INCREASING  SOCIALIZATION   OF   MEDICINE 

And  what  has  this  life  left  for  me : 
Nothing  but  my  thirty-three. 

Did  time  permit,  the  claims  of  preventive  medicine 
might  be  illustrated  in  the  facts  as  to  the  almost  com- 
plete annihilation  of  typhus  fever  in  this  country  and 
in  Great  Britain,  under  the  influence  of  hospital  segre- 
gation of  each  case,  of  supervision  of  contacts,  and  of 
increased  national  cleanliness;  in  the  rapid  reduction 
of  enteric  fever  brought  about  by  pure  water  and  milk 
supplies,  the  avoidance  of  sewage-contaminated  shell- 
fish, the  control  of  carriers  among  food  handlers,  and 
the  hospital  immobilization  of  cases ;  and  in  the  almost 
complete  abolition  of  smallpox,  secured  by  prompt 
recognition,  notification  and  isolation  of  each  case,  the 
searching  out  and  vaccination  of  all  contacts,  and  their 
continued  surveillance.  The  list  of  medical  triumphs, 
especially  in  tropical  diseases,  might  easily  be  extended. 
I  do  not  fail  to  remember  that  respiratory  infections 
have  hitherto  proved  refractory  to  preventive  meas- 
ures; and  that  common  catarrh,  pneumonia,  and  still 
more  influenza — as  also  cerebro-spinal  fever  and  po- 
liomyelitis— constitute  territories  on  which  the  flag  of 
public  health  has  not  yet  been  firmly  placed.  Tuber- 
culosis must  not  be  thought  of  in  the  same  category. 
It  is  a  controllable  disease,  so  soon  as  physicians,  pub- 
lic health  authorities  and  the  patients  themselves  will 
combine  on  an  adequate  scale  to  adopt  measures 
already  within  reach.  These  measures  will  be  less 


THE   INCREASING   SOCIALIZATION    OF    MEDICINE     77 

costly  than  the  present  position  of  partial  inertia; 
health  is  always  less  costly  than  disease,  and,  as  Dr. 
Herman  Biggs  has  often  reminded  us,  can  be  pur- 
chased within  natural  limits,  to  the  extent  which  we 
really  desire.  This  is  preeminently  true  for  tuber- 
culosis. 

Medical  triumphs  have  not  been  restricted  to  pre- 
ventive medicine.  Time  would  fail  me  to  speak  of 
the  introduction  of  general  anaesthetics  by  Morton 
and  Simpson,  which  has  rendered  possible  the  reaping 
of  the  full  harvest  of  the  work  of  Pasteur  and  Lister. 
Conversely  modern  surgery  has  itself  abolished  more 
pain  than  anaesthetics  themselves. 

The  chief  triumphs  of  modern  curative  medicine 
and  surgery  have  been  rendered  practicable  by  the 
more  accurate  study  of  disease  and  the  more  skilled 
attention  for  the  masses  of  the  population  obtainable 
in  hospitals.  The  steady  advance  in  the  provision  of 
skilled  nursing  has  kept  pace  with  medical  advance. 

Increasing  Importance  of  Hospitals 
From  a  return  prepared  by  the  Local  Government 
Board  in  1915  it  appears  that  the  number  of  hospital 
beds  in  England  and  Wales  (not  including  lunatic  asy- 
lums, tuberculosis  institutions,  or  convalescent  or  nurs- 
ing homes)  was  4.9  per  1,000  of  the  population.  In 
the  United  States,  according  to  the  Modern  Hospital 
Year  Book  for  1919,  the  number  of  hospital  beds 


78     THE   INCREASING  SOCIALIZATION   OF   MEDICINE 

amounts  to  6  per  1,000  of  the  population,  or  3.4  per 
1,000,  excluding  beds  for  mental  and  nervous  cases. 
It  is  not  certain  that  the  two  sets  of  figures  are  com- 
parable; but  in  both  instances  the  distribution  of  hos- 
pital provision  is  very  unequal,  and  large  tracts  of 
each  country  are  left  unprovided  with  available  hos- 
pital accommodation. 

Hospital  services  have  grown  in  a  manner  which  is 
characteristic  of  the  Anglo-Saxon :  first  largely  under 
\/  voluntary  management,  and  as  examples  of  Christian 
charity;  afterwards  continued  in  the  same  way,  but 
followed  by  official  provision  of  hospitals  on  an  even 
larger  scale,  the  two  systems  working  side  by  side. 
The  extent  to  which  the  more  satisfactory  institutional 
treatment  is  replacing  the  domiciliary  treatment  of 
disease  may  be  gathered  from  the  striking  facts  that 
in  England  and  Wales  one  in  every  nine  of  the  deaths 
from  all  causes  in  1881  occurred  in  public  institutions, 
and  in  1910,  one  in  every  five;  while  in  London  the 
proportion  increased  from  one  in  five  in  1881  to  two 
in  five  in  1910. 

The  facts  as  to  pulmonary  tuberculosis  are  even 
more  significant.  In  the  year  1911  in  England  and 
Wales  34  per  cent,  of  male  and  22  per  cent,  of  female 
and  in  London  59  per  cent,  of  male  and  48  per  cent, 
of  female  deaths  from  pulmonary  tuberculosis  oc- 
curred in  public  institutions.  As  each  of  the  patients, 
who  thus  had  the  solace  of  good  nursing  and  treat- 


THE   INCREASING  SOCIALIZATION   OF   MEDICINE     79 

ment  when  they  were  needed  most,  spent  on  an  aver- 
age several  months  in  hospitals,  at  the  most  infectious 
stage  of  their  illness,  an  important  annual  reduction 
in  the  possibility  of  massive  infection  of  relatives  and 
others  has  also  been  secured. 

Hospitals  as  a  Partial  Solution  of  Housing  Difficulties 
We  may  fairly  claim  that  general  and  special  hos- 
pitals have  been  important  agents,  not  only  in  reducing 
the  fatality  of  disease,  and  in  restoring  to  efficiency 
more  rapidly  than  in  the  past  a  large  proportion  of 
the  total  population ;  but  also  in  reducing  the  incidence 
of  tuberculosis,  of  syphilis,  and  of  other  diseases. 

The  public  indebtedness  to  hospitals  has  another 
aspect,  too  often  overlooked.  The  aggregation  during 
the  last  hundred  years  of  a  steadily  increasing  propor- 
tion of  our  population  in  crowded  towns  has  meant 
the  introduction  on  a  gigantic  scale  of  elements  inimi- 
cal to  health.  Smoke  and  obscuration  of  sunlight, 
dust  and  noise,  the  substitution  of  indoor  for  outdoor 
occupations,  the  difficulties  of  milk  supply  for  children, 
and  above  all  inferior  housing  with  associated  in- 
creased facilities  for  infection,  have  combined  to  ren- 
der healthy  life  in  towns  difficult  of  attainment.  Nor 
must  we  omit  from  the  adverse  side  of  the  balance 
sheet  the  greater  loneliness  of  family  life  in  towns,  the 
diminution  in  neighbourliness,  and  the  failure  of  public 
social  opinion  to  produce  the  wholesome  effect  on  con- 


8O     THE   INCREASING  SOCIALIZATION  OF   MEDICINE 

duct  which  it  exercises  in  village  life.  And  yet,  not- 
withstanding these  factors,  urban  death-rates  and 
especially  tuberculosis  death-rates  have  declined  more 
than  rural  death-rates,  and  in  parts  of  some  countries 
urban  is  even  lower  than  rural  mortality. 

Why  is  this  ?  Our  hospitals  provide  the  key  to  the 
mystery.  Parturition  is  freer  from  risk  in  town  than 
in  remote  country  districts ;  the  means  for  the  preven- 
tion of  infection  are  better  organized,  and  accident  and 
disease  are  more  promptly  and  more  efficiently  treated. 
The  poor  in  towns  receive  as  a  matter  of  course  in 
hospitals  better  treatment  gratuitously  than  king  or 
president  could  command  thirty  years  ago.  The  relief 
to  housing  deficiency  given  by  hospitals  comes  when 
most  needed,  in  the  emergencies  of  child-bearing  and 
of  sickness;  and  the  net  result  of  this  and  of  better 
sanitary  supervision  is  that  although  room-accommo- 
dation for  families  is  much  more  restricted  in  towns 
than  in  country  districts,  the  town-dwellers  have  a 
large  share  of  their  urban  handicap  removed  by  their 
superiority  over  country  people  in  medical  treatment. 

The  Continuing  Mass  of  Preventible  Disease 
The  medical  record  of  the  past  on  the  side  of  pre- 
ventive medicine  is  one  of  increasing  control  over  in- 
fectious diseases.  In  securing  this  result  epidemiolo- 
gists, pathologists,  and  vital  statisticians  can  rightly 
claim  first  place,  aided  by  the  sanitary  and  industrial 


THE   INCREASING   SOCIALIZATION   OF   MEDICINE     8 1 

inspector  and  the  sanitary  engineer ;  the  epidemiologist 
being  dependent  largely  on  the  work  of  the  pathologist 
and  of  the  statistician  for  guidance  in  his  field  investi- 
gations, which  have  led  to  the  discovery  and  removal 
of  numerous  sources  and  channels  of  infection. 

The  record  in  curative  medicine,  especially  on  its 
surgical  side,  is  one  of  increasing  triumph  over  serious 
disease  and  injury,  in  which  the  discovery  of  anaes- 
thetics and  of  Listerism  have  borne  an  essential  part. 

None  of  us  can,  however,  be  satisfied  with  the  suc- 
cess already  obtained,  and  I  have  elsewhere  given 
reasons  for  concluding  that  at  least  one-half  of  the 
mortality  and  disablement  still  occurring  at  ages  below 
70  can  be  obviated  by  the  application  of  medical 
knowledge  already  in  our  possession. 

The  Great  War  has  shown  both  in  Great  Britain 
and  in  America  the  extent  to  which  defects  and  disease 
exist  in  would-be  recruits  to  our  armies.  In  the 
United  Kingdom  only  two-fifths  of  a  large  section  of 
recruits  could  be  placed  in  the  first  grade ;  and  among 
American  recruits  out  of  two  and  one-quarter  million 
men  measured  and  examined  physically  at  local  boards 
29.1  per  cent,  were  rejected  on  physical  grounds; 
though  in  the  introduction  to  the  Official  Bulletin  (No. 
n,  March,  1919)  it  is  pointed  out  that  many  of  the 
disabilities  have  little  importance  in  civil  life,  and  that 
these  considerations  possibly  "reduce  to  15  per  cent, 
the  proportion  of  males  20  to  30  years  old  who  carry 
7 


82     THE   INCREASING   SOCIALIZATION    OF    MEDICINE 

a  serious  handicap  against  normal  activity  in  civil 
occupations." 

These  figures,  whatever  doubt  may  attach  to  their 
exact  arithmetical  value,  signify  the  existence  in  the 
community  of  a  large  amount  of  physical  disability 
which  must  greatly  reduce  the  sum  of  national  effi- 

(  ciency  and  happiness.  The  records  of  our  medical 
examinations  of  school  children  bring  out  the  same 

!  fact,  and  emphasize  the  necessity  not  only  for  school 
clinics  on  an  immensely  larger  scale  than  at  present, 
but  also  for  additional  medical  and  nursing  care  in 
connection  with  child-bearing  and  during  the  pre- 
school period,  which  would  discover  defects  and  dis- 
ease at  an  earlier  stage,  and  would  secure  the  provision 
not  only  of  early  preventive  treatment,  but  also  of 
more  systematic  improvement  of  the  sanitary  environ- 
ment of  maternity  and  childhood. 

Present  Extent  of  Socialisation  of  Medicine 
A  mental  effort  is  needed  to  realize  the  distance 
traveled  in  the  public  provision  of  medical  assistance 
in  the  United  Kingdom  by  the  state  and  by  voluntary 
organizations,  including  the  committees  of  hospitals, 
convalescent  homes,  dispensaries,  etc.,  prior  to  the 
passing  of  the  National  Insurance  Act  of  1911.  I 
have  already  given  some  illustrative  figures  regarding 
hospitals.  The  Lancet  some  years  ago  gave  a  state- 
ment of  the  number  of  attendances  of  patients  at  vol- 


THE    INCREASING   SOCIALIZATION    OF    MEDICINE     83 

untary  hospitals  in  London  during  the  year  1908. 
Assuming  that  each  out-patient  made  five  attendances, 
that  all  in-patients  had  previously  been  out-patients 
and  that  no  patient  received  a  hospital  or  dispensary 
letter  more  than  once  in  the  year,  it  could  be  inferred 
that  a  number  equivalent  to  one  in  four  of  the  total 
population  of  London  had  received  free  medical  aid 
in  these  voluntary  institutions  during  that  year.  And 
this  did  not  include  the  large  mass  of  treatment  given 
gratuitously  in  poor-law  infirmaries,  public-health  fe- 
ver and  tuberculosis  hospitals,  and  lunatic  asylums. 

The  majority  of  the  medical  profession  in  Great 
Britain  is  engaged  in  either  whole-time  or  part-time 
service  for  the  state  or  for  local  authorities.  Of  the 
24,000  medical  practitioners  in  England  and  Wales, 
some  5,000  are  engaged  as  poor-law  doctors,  some 
4,000  or  5,000  in  the  public-health  service,  possibly 
500  in  the  lunacy  service,  some  1,300  in  the  school 
medical  service,  and  smaller  numbers  in  various  other 
forms  of  medical  service  for  the  state.  This  is  ex- 
clusive of  the  general  practitioners  who  undertake 
contract  work  under  the  National  Insurance  Act,  and 
who  cannot  fall  far  short  of  three-fourths  of  the  total 
membership  of  the  profession.  It  should  be  noted 
that  many  doctors  hold  several  appointments. 

The  state  has,  quite  apart  from  National  Insurance, 
given  a  rapidly  increasing  amount  of  medical  assist- 
ance to  the  public. 


84     THE    INCREASING   SOCIALIZATION   OF    MEDICINE 

1.  Under  the  Poor  Law,  every  destitute  person  is 
entitled  to  gratuitous  medical  attendance,  at  home  or 
in  an  institution,  and  after  a  fashion  has  received  this 
during  the  last  century. 

2.  The  institutional  treatment  of  lunacy  has  grown 
to  an  extent  which  permits  the  treatment  in  an  asylum 
of  every  certified  lunatic. 

3.  The  treatment  at  the  expense  of  the  state  of 
feeble-minded  persons  is  rapidly  increasing. 

4.  Public   health   authorities   provide   institutional, 
and  to  a  limited  extent  domiciliary,  treatment  of  in- 
fectious diseases,  this  treatment  being  given,  as  in  the 
preceding  cases,  in  nearly  every  instance  gratuitously. 

5.  To  some  extent  prior  to,  and  to  an  increased 
extent  since,  the  passing  of  the  National  Insurance 
Act,  sanatoriums  and  hospitals  for  the  treatment  of 
tuberculosis  are  provided  by  the  public  health  authori- 
ties, the  central  government  contributing  to  the  local 
authority  undertaking  this  duty  one-half  of  all  ap- 
proved expenditure  on  these  institutions,  on  tubercu- 
losis clinics,  and  of  the  expenses  incurred  in  the  domi- 
ciliary nursing  and  supervision  of  tuberculosis  patients. 

6.  Similarly  the  central  government  pays  one-half 
of  the  approved  expenditure  incurred  by  local  authori- 
ties or  in  certain  cases  by  voluntary  agencies  in  assist- 
ance given  in  aid  of  maternity  and  child  welfare,  e.g., 
in  the  provision  of  midwives,  of  consultant  doctors, 
of  lying-in  homes  and  hospitals,  of  beds  for  prsepar- 


THE    INCREASING   SOCIALIZATION   OF    MEDICINE     85 

turn  treatment,  of  convalescent  homes  for  mothers  or 
their  children,  of  infant  consultations  and  clinics,  etc. 

7.  In  regard  to  venereal  diseases  the  central  govern- 
ment has  gone  still  further.     It  has  made  it  obligatory 
on  the  larger  local  authorities  to  provide  facilities  for 
pathological  diagnosis,  and  for  the  treatment  of  pa- 
tients suffering  from  these  diseases  irrespective  of  any 
residential    or    financial    limitations.     Arseno-benzol 
preparations  are  given  gratuitously  to  medical  practi- 
tioners, as  also  laboratory  assistance  in  diagnosis.     To 
ensure  the  success  of  the  local  arrangements  the  cen- 
tral government  pays  three-fourths  of  their  total  cost ; 
and  have  passed  an  act  which  prohibits  the  treatment 
of  venereal  diseases  by  any  unqualified  person,  as  also 
the  advertisement  or  sale  of  any  remedies  for  these 
diseases. 

8.  Many  public  health  authorities  provide  gratuitous 
assistance  to  medical  practitioners  in  the  bacteriolog- 
ical  diagnosis   of   tuberculosis,   enteric    fever,    diph- 
theria, etc.     Recently  Wasserman  tests  and  searches 
for  gonococci  and  spirochaetes  have  been  added.     In 
1914  plans  for  further  development,  including  the  pro- 
vision of  complete  clinical  laboratories  for  the  gratui- 
tous use  of  practitioners  had  been  planned,  and  the 
necessary  grant  had  been  obtained  from  Parliament; 
but  the  war  led  to  the  plans  remaining  in  abeyance. 
At  the  same  time  government  grants  in  aid  of  nursing, 
and  of  the  provision  of  consultants  and  referees  for 


86     THE    INCREASING   SOCIALIZATION   OF    MEDICINE 

insured  patients  were  passed,  but  were  similarly  held 
in  abeyance. 

9.  The  local  education  authorities  provide  for  the 
medical  inspection  of  each  scholar  in  elementary  day 
schools  several  times  during  the  nine  years  of  his  com- 
pulsory attendance  at  school.  Parents  are  advised  as 
to  treatment  needed,  in  suitable  cases  are  referred  to 
hospitals  (payment  being  made  by  the  education  au- 
thorities), and  for  an  increasing  number  of  conditions 
actual  treatment  is  provided  at  school  clinics  (teeth, 
eyes,  ringworm,  etc.). 

The  above  enumeration,  which  does  not  include  the 
recently  necessitated  activities  of  the  Pensions  Depart- 
ment for  sailors  and  soldiers,  and  those  under  the  Na- 
tional Insurance  Act,  is  not  otherwise  complete;  but 
it  serves  to  indicate  that  the  state  is  already  committed 
very  deeply  to  provide  for  the  medical  needs  of  the 
community.  That  the  work  done  on  behalf  of  the 
community,  plus  the  work  accomplished  by  private 
medical  practitioners,  is  not  equal  to  national  needs  is 
obvious  to  any  one  considering  the  vast  amount  of 
avoidable  disease  in  our  midst.  Why  is  this  and  what 
is  the  remedy?  A  partial  answer  is  given  by  English 
experience.  The  medical  provision  made  in  a  large 
proportion  of  cases  is  belated  and  inadequate;  and  in 
perhaps  a  still  larger  proportion  of  cases  medical  ad- 
vice is  not  obtained,  or  being  obtained,  is  not  followed. 
This  applies  even  more  to  hygienic  than  to  clinical 
medical  advice. 


THE   INCREASING  SOCIALIZATION   OF   MEDICINE     87 

Destitution  and  Sickness 

It  was  one  of  the  greatest  misfortunes  in  the  history 
of  medicine  in  England  that  poor  law  medicine  and 
public  health  medicine  were  not  administratively  com- 
bined when  the  Local  Government  Board  was  formed 
in  1870,  and  that  the  preventive  ideals  of  public  health 
were  not  allowed  to  operate  in  the  treatment  and  su- 
pervision of  the  destitute.  Although  there  has  been 
a  fairly  steady  improvement  in  the  conditions  of  med- 
ical treatment  under  the  poor  law,  its  association  with 
the  deterrent  general  policy  of  that  department  of 
state,  as  well  as  its  actual  defects,  culminated  in  the 
appointment  of  a  royal  commission  of  inquiry,  which 
in  1909  presented  reports  recommending  the  abolition 
of  the  local  boards  of  guardians  and  transference  of 
their  duties  to  the  larger  public  health  authorities. 

Behind  these  proposals  of  the  royal  commission  lay 
the  absolutely  sound  principle — which  many  years  pre- 
viously had  been  recognized  by  the  pioneers  of  public 
health — that  the  treatment  and  the  prevention  of  dis- 
ease cannot  administratively  be  separated  without  in- 
juring the  possibilities  of  success  of  both.  The  public 
health  activities  preceding  the  report  of  the  royal  com- 
mission illustrate  this  axiom,  such  as  the  isolation  and 
treatment  of  infectious  cases,  the  treatment  of  tuber- 
culosis, the  provision  for  the  care  of  parturient  women 
and  of  their  infants,  and  the  medical  inspection  and 
treatment  of  school  children. 


88     THE   INCREASING  SOCIALIZATION   OF   MEDICINE 

It  was  an  even  greater  misfortune  to  the  satisfactory 
progress  of  public  medicine  that  the  report  of  the  royal 
commission  on  the  poor  laws  was  not  followed  by  leg- 
islation on  the  lines  of  its  recommendations.  So  much 
of  destitution  is  associated  with  sickness,  and  sickness 
is  the  cause  of  such  a  preponderant  share  of  the  total 
destitution  in  our  midst,  that  the  continued  adminis- 
trative separation  of  the  two  problems  of  poverty  and 
sickness  is  inconsistent  with  a  full  measure  of  success. 

Had  the  transfer  of  the  duties  of  the  poor  law  au- 
thorities to  the  councils  of  counties  and  county  bor- 
oughs been  adopted,  and  ancillary  legislation  enacted, 
the  public  health  organization  would  have  at  once 
possessed  a  medical  service  for  the  poor  of  some  4,000 
doctors,  in  addition  to  the  doctors  already  engaged  in 
the  public  health  service ;  it  would  have  had  large  in- 
firmaries and  the  other  medical  institutions  of  both 
services;  would  have  been  able  to  make  liaison  work- 
ing arrangements  with  the  committees  of  voluntary 
hospitals ;  and  there  would  have  been  secured  a  greatly 
improved  medical  service,  freed  from  poor-law 
shackles,  which  could  gradually  be  extended  as  needs 
and  policy  indicated. 

Insurance  versus  Public  Health 
Political  circumstances   led  to  the  adoption  of  a 
course  which  medically  ran  directly  athwart  the  course 
of  needed  reform.     The  National  Insurance  Act  of 


THE   INCREASING  SOCIALIZATION   OF   MEDICINE     89 

1911  was  passed,  giving  sickness  and  invalidity  benefits 
to  all  employed  manual  workers  and  to  others  below 
an  income  limit  of  £160  (recently  increased  to  £250), 
who  could  contribute  a  weekly  sum  which  was  con- 
siderably less  than  half  of  the  estimated  cost  of  the 
benefits  to  be  received ;  and  a  new  medical  service  was 
created,  further  complicating  administratively  the  al- 
ready existing  medical  services  of  the  poor  law,  public 
health,  and  educational  authorities,  and  converting  the 
majority  of  general  practitioners  into  part-time  civil 
servants. 

The  case  is  an  illustration  of  the  moral  contagious- 
ness under  modern  conditions  of  life,  of  a  new  course 
adopted  in  any  country.  Bismarck's  attempt  to  coun- 
teract socialism  by  insurance  has  been  responsible  for 
state  and  official  experimentation  in  insurance  in 
many  countries,  which  at  least  in  England  was  not 
actuarily,  financially,  or  medically  sound,  and  which 
has  involved  expenditure  in  administration  entirely  in- 
commensurate with  the  benefits  received. 

Insurance  against  sickness  and  disability  is  a  praise- 
worthy and  valuable  provision  against  future  contin- 
gencies. I  am  not  concerned  here  to  point  out  in- 
equalities to  the  insured  in  the  English  Insurance  Act 
inherent  in  the  apportionment  of  a  flat  rate  for  all 
ages,  districts  and  occupations,  and  for  both  sexes, 
irrespective  of  known  or  suspected  incidence  of  sick- 
ness, nor  the  difficulties  created  by  continuing  the  non- 


9O     THE   INCREASING   SOCIALIZATION   OF    MEDICINE 

localized  work  of  friendly  societies  and  other  private 
organizations,  and  at  the  same  time  creating  local  in- 
surance committees,  who  furthermore  were  not  organ- 
ically related  to  local  health  authorities,  and  had  no 
opportunity,  therefore,  to  develop  the  conceivable  po- 
tentialities of  insurance  experience  as  an  aid  to  public 
health  work.  The  act  in  its  present  form  is  now  gen- 
erally condemned;  and  it  is  significant  that  the  need 
for  its  radical  reorganization  appears  to  be  universally 
accepted.2 

2  Thus  Mr.  Bishop  Harman,  an  ophthalmic  surgeon,  and  a 
member  of  the  Council  of  the  British  Medical  Association, 
says: 

"  In  my  out-patient  clinic  60%  of  the  patients  are  insured 
persons  who  attend  for  treatment  that  is  essential  to  their 
industrial  efficiency.  ...  A  scheme  of  medical  benefit  which 
does  not  provide  for  specialist  service  and  for  institutional 
treatment  is  no  scheme,  it  is  poorer  in  status  than  the  Poor 
Law  provision  which  does  all  these  things."  (British  Medical 
Journal,  Mar.  15,  19). 

Dr.  R.  Sanderson,  of  Brighton,  writing  on  behalf  of  medi- 
cal practitioners,  says: 

"  We  are  the  victims  of  a  half-fledged,  inadequate  piece  of 
legislation  which  is  founded  apparently  on  the  supposition  that 
disease  can  be  dealt  with  effectually  by  giving  bottles  of  medi- 
cine or  liniment  to  the  sick,  or  that  if  this  fails  and  the  sick 
get  worse,  they  can  be  sent  to  one  of  the  overcrowded  volun- 
tary hospitals  with  which  the  legislature  has  nothing  whatever 
to  do.  Anything  more  unsatisfactory  to  the  sick,  or  demor- 
alizing to  us  as  a  profession,  it  is  hard  to  imagine." 

He  then  proceeds  to  advocate  an  urgent  need  of  the  pro- 
fession, viz :  the  establishment  of  an  adequate  number  of 


THE   INCREASING  SOCIALIZATION   OF   MEDICINE     91 

Two  medical  benefits  (medical  and  sanatorium)  and 
a  maternity  benefit  were  conferred  under  the  act ;  but, 
as  they  have  been  administered,  it  cannot  be  affirmed 
that  any  marked  public  benefit  has  accrued;  and  it  is 
certain  that  if  the  same  amount  of  money  had  been 
placed  in  the  hands  of  public  health  authorities  to  pro- 
vide adequate  medical  aid  to  those  needing  it,  of  the 
kind  most  lacking  and  which  they  could  least  afford 
to  obtain,  great  benefit  to  the  public  health  would  have 
been  secured. 

What  was  given  ?  ( i )  There  was  the  medical  ben- 
efit, each  insured  person  being  entitled  to  the  services 

auxiliary  hospitals  throughout  the  country,  staffed  by  teams 
of  general  practitioners,  to  which  all  practitioners  can  have 
access,  and  to  which  they  can  send  cases  requiring  clinical 
observation  of  any  kind,  rest  or  treatment  that  cannot  be 
carried  out  in  the  sick  person's  home.  (British  Medical  Jour- 
nal, July  19,  19.) 

Dr.  Howarth,  Medical  Officer  of  Health  of  the  City  of 
London,  and  Dr.  B.  A.  Richmond,  Secretary  of  the  London 
Panel  Committee,  affirm  "  the  limitation  of  medical  benefit 
to  insured  persons  alone  cannot  continue.  Another  service 
has  been  added  to  the  many  competing  classes  of  state  treat- 
ment " ;  and  they  bring  out  the  fact  that  personal  contributions 
of  insured  persons  are  swallowed  up  in  supplying  the  sickness 
and  disablement  benefit,  and  contribute  nothing  to  the  cost  of 
the  sanatorium  benefit,  maternity  benefit,  or  medical  benefit. 

Dr.  H.  S.  Beadles,  Secretary  of  the  Stratford  &  West  Ham 
Panel  Committee,  says :  "  The  British  Medical  Association 
should  fearlessly  acknowledge  that  the  attendance  under  the 
National  Insurance  Act,  which  is  itself  a  part-time  State 
service,  is  an  absolute  failure  and  amounts  to  little  more  than 
first  aid,  carried  on  at  an  enormous  cost." 


92     THE   INCREASING  SOCIALIZATION   OF   MEDICINE 

of  a  medical  practitioner  of  his  own  choice  (a  "  panel " 
doctor).  The  services  given  were  limited  by  regula- 
tion to  mean  such  medical  attendance  as  is  "within 
the  ordinary  professional  competence  and  skill"  of  a 
medical  practitioner;  and  so  the  treatment  given  has 
often  been  more  limited  than  what  is  given  by  the 
more  advanced  poor  law  authorities.  The  latter  can 
supply  hospital  treatment  and  expert  assistance  when 
required;  under  the  insurance  system  no  such  pro- 
vision is  made.  The  insured  patient  is  not  entitled 
to  surgical  operations  when  needed,  except  of  the  sim- 
plest character;  treatment  of  eye,  ear,  nose  and  teeth 
conditions  is  commonly  excluded;  no  appliances  are 
given  except  a  few  bandages  and  simple  splints;  and 
there  are  no  facilities  for  modern  scientific  laboratory 
investigation,  except  those  provided  gratuitously  by 
public  health  authorities.  Furthermore,  by  the  rules 
of  most  friendly  societies  sickness  (monetary)  benefit 
during  treatment  of  illness  due  to  the  patient's  miscon- 
duct is  excluded. 

The  title  of  the  act — National  (Health)  Insurance 
Act — has  hitherto  proved  a  misnomer.  The  panel  or 
contract  system  of  medical  treatment  of  insured  per- 
sons has  done  much  to  continue  the  obsession  of  the 
public  with  the  conception  of  medical  care  as  consist- 
ing of  a  "visit  and  a  bottle";  and  so  long  as  the 
doctor's  medical  work  is  on  the  present  basis,  and  he 
is  under  the  constant  temptation,  not  only  to  accept 


THE   INCREASING   SOCIALIZATION   OF    MEDICINE     93 

more  patients  on  his  panel  than  he  can  satisfactorily 
treat  and  to  give  each  patient  on  application  the  men- 
tal satisfaction  of  a  "  bottle,"  but  also  to  be  more  than 
lenient  in  the  giving  of  sickness  certificates,  it  will 
remain  questionable  whether  on  the  balance  state  in- 
surance against  sickness  does  more  good  than  harm. 
If  medical  consultants  and  referees,  treatment  centres, 
and  hospitals  are  in  the  future  provided  for  insured 
patients,  this  will  mitigate  the  evils  of  the  panel  sys- 
tem ;  but  the  present  contributions  of  patients  will  not 
purchase  this  additional  provision.  All  the  new  money 
needed,  and  most  of  the  money  needed  under  present 
conditions,  must  continue  to  be  provided  by  the  state 
and  employers  of  the  insured  (a  form  of  taxation)  ; 
and  provisions  thus  made,  like  the  present  contribu- 
tions of  the  state  for  insured  persons,  are  in  direct 
contravention  of  the  general  principle  that  govern- 
ment grants  being  derived  from  the  whole  community, 
should  enure  to  the  benefit  of  the  whole  community 
in  need  of  them,  and  not  only  to  the  benefit  of  a  sec- 
tion of  it. 

About  one-third  of  the  total  population  of  Great 
Britain  is  included  within  the  terms  of  the  National 
Insurance  Act.  If  the  wives  and  children  of  insured 
men  were  also  included,  as  has  been  proposed,  over 
two-thirds  of  the  total  population  would  be  embraced 
in  the  scheme ;  but  as  persons  manually  employed,  but 
working  for  themselves — e.g.,  cotters  and  hawkers,  are 


94     THE   INCREASING   SOCIALIZATION    OF    MEDICINE 

encluded,  and  as  persons  not  manually  employed  can- 
not be  insured  unless  their  income  is  below  £160  (re- 
cently raised  to  £250),  large  classes  of  the  population 
who  can  ill-afford  to  pay  for  their  own  medical  at- 
tendance are  excluded  from  the  operation  of  the  act, 
and  taxed  to  pay  the  benefits  of  insured  persons. 

(2)  The  sanatorium  benefit  was  intended  to  secure 
for  the  insured  person  special  treatment  for  tuber- 
culosis, while  capital  sums  were  provided  for  the  erec- 
tion of  sanatoria  and  hospitals  for  consumptives  for 
insured  and  non-insured  alike.  Fortunately  during  the 
passage  of  the  bill,  the  provision  of  these  institutions 
for  insured  persons  was  delegated  to  public  health 
authorities;  and  as  it  was  already  within  the  power 
of  these  authorities  to  provide  such  institutions  and 
tuberculosis  clinics  for  the  entire  population,  and  as 
the  infection  of  tuberculosis  is  no  respecter  of  parlia- 
mentary distinctions  between  insured  and  non-insured, 
there  was  little  difficulty  in  persuading  the  government 
to  promise  half  the  total  approved  local  expenditure 
on  the  treatment  of  tuberculosis  in  institutions,  whether 
this  was  given  to  insured  or  non-insured  persons.  In- 
deed when  local  authorities  were  willing  to  undertake 
their  share  in  a  complete  scheme  for  the  treatment  of 
tuberculosis  an  insured  consumptive  person  might  be 
regarded  even  as  paying  fractionally  for  his  treatment 
while  a  non-insured  person  received  such  treatment 
gratuitously. 


THE    INCREASING   SOCIALIZATION    OF    MEDICINE     95 

(3)  The  maternity  benefit,  conferring  thirty  shil- 
lings on  the  wife  of  an  insured  person,  and  an  addi- 
tional thirty  shillings  if  she  also  is  an  employed  person 
within  the  meaning  of  the  act,  on  the  birth  of  her  in- 
fant, was  perhaps  the  most  popular  benefit  under  the 
act.  The  money  was  given  unconditionally,  and  thus 
an  opportunity  was  lost  of  insuring  that  the  benefit 
should  improve  maternal  and  infantile  prospects. 

Collaterally  public  health  authorities,  central  and 
local,  were  beginning  to  organize  medical  and  nursing 
assistance  during  pregnancy,  in  confinement  and  after- 
wards for  the  mother,  and  similar  assistance  on  a  large 
scale  for  infants  and  children  under  five  years  of  age. 
And  there  will,  I  think,  be  no  hesitation  in  agreeing 
that  the  supply  of  service  at  this  critical  period  of  the 
mother's  and  infant's  life,  so  as  to  insure  the  most 
satisfactory  recovery  of  parent  and  the  best  start  in 
infantile  life,  is  infinitely  more  important  than  a  money 
grant. 

I  cannot  pretend  to  have  more  than  touched  on  the 
fringe  of  the  complicated  subject  of  insurance  in  rela- 
tion to  public  health.  The  inauguration  of  the  act 
meant  an  enormous  increase  in  the  direct  relationship 
of  the  medical  profession  to  the  state.  A  great  stride 
in  the  socialization  of  medicine  was  taken.  But  it  was 
done  ill-advisedly ;  it  continued  a  false  and  low  ideal 
of  isolated  general  medical  practice;  it  has  even  been 
described  as  a  fraud  on  the  insured,  in  view  of  the 


96     THE    INCREASING   SOCIALIZATION    OF    MEDICINE 

incompleteness  of  the  medical  service  provided;  and 
it  diverted  into  an  unsatisfactory  channel  the  energy 
and  money  which  were  urgently  needed  for  the  im- 
mense good  obtainable  by  reform  of  poor  law  and 
public  health  administration,  and  extension  of  their 
medical  services.  Had  the  lines  indicated  by  history 
and  experience  and  by  the  report  of  a  strong  royal 
commission  on  the  poor  law — there  was  a  majority 
and  a  minority  report,  but  both  agreed  in  the  chief 
essential  points — been  followed,  England  would  now 
possess  a  nearly  completely  unified  state  medical  serv- 
ice, instead  of  standing  at  the  point  whence  false  steps 
need  to  be  retraced,  with  a  view  to  a  coordinated  and 
simplified  medical  and  public  health  policy.  With  the 
principle  of  contributory  insurance  to  secure  monetary 
support  during  illness  there  can  be  no  quarrel ;  but  in 
the  interest  of  national  efficiency  complete  medical  pro- 
vision, preventive  and  curative,  must  be  made  by  the 
state,  irrespective  of  insurance,  for  all  in  need  of  it; 
and  the  medical  practitioners  employed  in  the  neces- 
sary certification  of  such  insurance  work  as  is  con- 
tinued must,  if  the  insurance  is  to  be  satisfactory,  be 
employed  under  conditions  which  will  render  them 
independent  of  the  favor  of  the  insured,  and  will  en- 
able them  to  utilize  their  knowledge  of  each  patient's 
case  for  the  needed  preventive  measures,  whether 
these  be  concerned  with  the  sanitation  of  home  or  fac- 
tory or  workplace,  or  with  personal  habits. 


THE    INCREASING   SOCIALIZATION    OF    MEDICINE     97 

The  Need  of  the  Future 

It  is,  I  think,  clear  that  the  state  will  year  by  year 
take  an  increasing  hand  in  medical  matters.  It  is  use- 
less, even  if  it  were  desired,  to  attempt  to  oppose  the 
inevitable  and  the  eminently  desirable  trend  towards 
vastly  increased  utilization  by  the  state  of  medical  sci- 
ence in  the  interests  of  humanity.  It  is  for  physicians 
to  guide  the  course  of  events,  and  to  insure  that  no 
plant  is  sown  which  will  afterwards  need  to  be  up- 
rooted; that  no  development  is  permitted  which  will 
hinder  the  fulfillment  of  our  ideal.  Personal  hygiene 
forms  a  rapidly  increasing  part  of  public  health  work ; 
hence  it  is  indispensable  that  all  forms  of  public  med- 
ical service  shall  be  linked  up  with  the  public  health 
service  and  controlled  locally  and  centrally  in  accord- 
ance with  this.  This  may  imply — and  in  England  it 
does  imply — the  urgent  need  for  reform  and  recon- 
struction of  local  as  well  of  central  public  health  ad- 
ministration ;  but  to  attempt  to  separate  medical  from 
public  health  provision  is  to  repeat  the  blunders  which, 
despite  skilled  advice  to  the  contrary,  have  been  made 
on  two  great  historic  occasions. 

A  complete  service,  adequate  to  the  needs  of  the 
community,  cannot  be  secured  by  a  session's  legisla- 
tion. It  must  grow  as  the  result  of  steady  advance. 
The  motto  in  growth  might  well  be,  "First  things 
first."  What  are  the  medical  services  which  are  pro- 
vided too  sparsely  at  the  present  time  and  for  which 
8 


98     THE  INCREASING  SOCIALIZATION   OF   MEDICINE 

the  masses  of  the  population  cannot  afford  individually 
to  pay,  except  possibly  to  a  fractional  extent  ?  There 
can  be  no  doubt  as  to  the  answer.  What  is  most 
urgently  needed  is  the  provision  of  skilled  hospital 
attendance  for  every  patient  who  can  be  more  satisfac- 
torily treated  in  hospital  than  at  home.  Next  to  this 
comes  the  provision  of  gratuitous  medical  services — 
(e.g.,  maternity  and  infant  consultations,  eye,  throat, 
ear,  skin  and  venereal  diseases,  tuberculosis,  X-ray  de- 
partments) preferably  linked  around  a  hospital,  where 
patients  can  be  sent  by  private  practitioners  for  an 
expert  opinion,  or  in  certain  cases  may  present  them- 
selves independently.  And  as  important  as  either  of 
the  preceding  desiderata,  is  the  provision  of  a  com- 
plete nursing  service,  on  which  each  private  practi- 
tioner can  call  for  assistance  as  required,  payment,  if 
any  is  exacted,  being  on  the  easiest  possible  conditions, 
and  not  made  compulsory. 

The  hospital  under  such  circumstances  would  be- 
come a  centre  from  which  community  work  of  the 
highest  value  would  radiate;  and  patients,  private 
practitioners,  and  the  staffs  of  hospitals  would  alike 
live  in  a  new  world  in  which  the  interest  and  efficiency 
of  medical  work  would  be  greatly  increased.  The 
present  irregular  localization  of  hospitals  makes  the 
realization  of  such  a  scheme  difficult;  but  local  par- 
tially successful  schemes  are  already  in  operation; 
difficulties  can  be  overcome  with  good-will ;  and  even- 


THE   INCREASING   SOCIALIZATION    OF    MEDICINE     99 

tually  we  may  hope  to  have  for  each  unit  of  sub- 
divided public  health  administration  and  as  an  organic 
part  of  this,  a  hospital,  with  out-patient  or  dispensary 
clinics,  and  radiating  from  these  the  various  forms  of 
medical  attendance,  domiciliary  nursing,  public  health 
nursing,  and  sanitary  supervision  which  are  needed. 

In  securing  such  a  result  there  will  be  needed  med- 
ical practitioners  who  are  imbued  with  the  ideals  of 
preventive  medicine  in  its  widest  sense.  Let  me,  in 
this  connection  quote  the  following  extract  from  a 
recent  official  report  of  my  own: 

There  is  needed  a  reconstruction  of  the  training  of  each 
medical  student,  which  will  make  preventive  medicine  in  its 
widest  sense  an  integral  part  of  his  training,  and  will  insure 
that  before  he  begins  practice  he  has  definite  instruction  in 
the  application  of  the  whole  of  his  knowledge  to  preventive 
purposes.  The  past  conception  by  the  public  of  the  relation 
of  medical  men  to  the  community — apart  from  the  special  case 
of  medical  officers  of  health — has  been  mistaken.  The  doctor 
has  been  regarded  as  a  help  when  serious  or  acute  incapaci- 
tating illness  occurs,  and  he  has  but  seldom  had  the  oppor- 
tunity of  giving  advice  in  the  earlier  and  more  controllable 
stages  of  illness.  His  training  has  been  conducted  on  the 
assumption  that  his  chief  role  should  be  on  present  lines, 
with  the  result  that  most  medical  practitioners  enter  into  prac- 
tice with  a  too  scanty  knowledge  of  hygiene  and  preventive 
medicine,  and  have  to  learn  slowly  in  belated  experience  the 
influence  of  environment  on  the  health  of  their  patients.  The 
teaching  of  medicine  should  be  much  more  largely  physio- 
logical and  hygienic  than  at  present,  and  such  subjects  as  food 
values,  the  hygiene  of  infancy  and  childbirth,  the  physiology 
of  breast  feeding,  and  the  influence  of  environment  on  the 
health  of  their  future  patients  should  be  the  subject  of  careful 


IOO  THE   INCREASING   SOCIALIZATION    OF    MEDICINE 

training — especially  in  regard  to  housing,  feeding,  clothing, 
and  conditions  of  work.  Were  this  done,  the  ideal  condition, 
in  which  each  medical  practitioner  becomes  a  medical  officer 
of  health  in  the  range  of  his  own  practice,  would  approach 
realization. — [Annual  Report  to  the  Local  Government  Board, 
1917-18.] 

Many  medical  practitioners  already  fulfill  this  ideal. 
It  would  oftener  be  realized  were  it  not  for  the  ex- 
cessive work  which  many  are  obliged  to  undertake. 
In  the  early  history  of  public  health  in  England  poor 
law  medical  officers,  attending  the  impoverished  in 
their  dwellings  and  familiar  with  their  home  condi- 
tions, became  part-time  medical  officers  of  health. 
But  the  attempt  to  combine  prevention  and  treatment 
proved  unsuccessful,  because  these  officers  visited  only 
a  small  proportion  of  the  dwellings  of  the  poor,  be- 
cause they  were  not  trained  in  preventive  work,  and 
because  the  good  seed  of  preventive  work  was  choked 
by  the  increasing  demands  of  lucrative  private  prac- 
tice. In  connection  with  the  future  general  medical 
service,  curative  as  well  as  preventive,  it  is  not  beyond 
the  range  of  human  ingenuity  to  provide  schemes  for 
district  medical  officers  (health  and  clinical)  adequately 
trained  in  public  health  work,  and  linked  up  closely 
with  the  hospital  and  dispensary  unit  for  their  area. 

This  will  cost  money.  But  sound  health  is  our 
greatest  personal  and  national  asset,  and  disease  is 
always  more  expensive  than  health.  "  Who  winds  up 
days  with  toil,  and  nights  with  sleep  "  has  "  the  fore- 


THE   INCREASING  SOCIALIZATION   OF   MEDICINE  IOI 

hand  and  vantage  of  the  king,"  if  the  latters  suffers  in 
body  or  mind.  The  real  wealth  of  a  nation  does  not 
consist  in  its  money,  in  the  volume  of  its  trade,  or  in 
the  extent  of  its  dominion.  These  are  only  valuable 
insofar  as  they  help  to  maintain  a  population — and  not 
only  a  portion  of  it — of  the  right  quality ;  men,  women 
and  children  possessing  bodily  vigor,  alert  mind,  firm 
character,  courage  and  self-control.  This  ideal  can 
never  be  realized  unless  and  until  the  medical  men  of 
the  future  train  themselves  for  and  devote  themselves 
to  their  essential  share  in  its  fulfillment,  and  while 
keeping  this  ideal  in  view  see  to  it  that  every  step 
taken  is  one  which  will  be  consistent  with  the  complete 
scheme  of  the  future. 

We  are  all  concerned  in  the  efficiency  of  every  mem- 
ber of  the  community,  from  an  economic  as  well  as 
from  a  humanitarian  standpoint.  Can  we  be  satisfied 
while  a  large  proportion  of  the  population  do  not 
obtain  medical  and  ancillary  assistance  to  the  extent  of 
their  needs?  Does  such  a  state  of  things  conduce  to 
the  settlement  of  social  unrest?  Is  it  consistent  with 
Christian  principles? 

If  communal  provision  has  been  recognized  as  a 
duty  for  police  protection,  for  sanitation,  for  elemen- 
tary education,  should  it  not  likewise  be  admitted  for 
the  more  subtle  and  maleficent  enemies  of  health 
which  have  been  recognized,  but  which  in  no  commu- 
nity have  hitherto  been  completely  combatted? 


IO2  THE   INCREASING   SOCIALIZATION    OF   MEDICINE 

We  scarcely  realize  how  far  we  have  gone  in  the 
socialization  of  medicine.  It  is  impossible  to  go  back, 
or  to  stand  still.  The  services  of  the  medical  pro- 
fession are  needed,  not  only  to  provide  the  necessary 
service,  but  in  helping  to  determine  its  conditions. 
One  essential  item  will  be  the  substitution  for  fees 
during  sickness  of  an  annual  payment  to  private  prac- 
titioners by  each  family  for  supervising  its  members 
in  health,  for  inquiry  into  their  industrial  and  domestic 
life,  so  far  as  it  contains  elements  inimical  to  health, 
and  for  giving  preventive  more  than  curative  advice. 
The  second  and  most  urgent  element  consists  in  the 
organization  of  hospital  and  consultative  expert  serv- 
ices for  all,  which,  while  greatly  increasing  each  pa- 
tient's prospect  of  prompt  recovery,  will  enable  the 
general  practitioner  to  escape  from  the  soul-destroying 
inefficiency  of  unaided  medical  practice. 

Of  course,  any  service  provided,  whether  partial  or 
complete,  will  need  to  be  kept  free  from  "political 
pull."  This  spells  inefficiency;  and  inefficiency  means 
disease  and  death.  "  Political  pull,"  although  not  in 
the  official  list  of  Causes  of  Death,  is  among  the  potent 
causes  of  excessive  mortality ;  and  for  this,  every  one 
of  us  must  bear  his  individual  share  of  responsibility, 
insofar  as  we  have  abstained  from  active  support  of 
sound  and  clean  government,  when  we  were  unable 
to  take  an  actual  share  in  government. 


CHAPTER  IV 

INSURANCE  AND  HEALTH1 

So  far  as  a  majority  of  the  population  are  concerned, 
it  is  necessary  to  realize  that  they  are  never  far  re- 
moved from  the  line  dividing  destitution  from  ade- 
quacy, using  the  word  destitution  to  mean  insufficiency 
or  lack  of  some  provision  essential  for  health  and  con- 
tinued welfare. 

It  may  be  urged  that  this  is  owing  in  large  measure 
to  the  improvidence  or  thriftlessness  of  the  wage- 
earners  who  are  chiefly  concerned;  but  such  a  state- 
ment fails  to  appreciate  the  higher  standard  of  conduct 
and  the  greater  self-denial  which  is  demanded  from 
weekly  wage-earners  than  from  ourselves,  if  out  of 
their  wages  provision  is  to  be  made  for  a  "  rainy  day," 
without  affecting  unfavourably  the  present  health  of 
the  worker  or  his  family. 

The  general  appreciation  of  the  above  considera- 
tions has  led  to  the  provision  of  non-contributory  old- 
age  pensions  in  the  United  Kingdom ;  and  similar  sen- 
timents have  led  in  many  countries  to  compensation 
for  accidents  at  the  expense  of  employers ;  and  to  the 

1  An  address  given  to  the  Quiz  Medical  Society,  New  York, 
Feb.  14,  1920. 

103 


104  INSURANCE   AND    HEALTH 

various  national  systems  of  insurance  against  sickness. 
With  the  principle  of  sickness  insurance  there  can  be 
no  quarrel.  It  is  the  substitution  of  cooperative  for 
individual  provision,  thereby  distributing  some  of  the 
loss  and  eliminating  some  of  the  risk  of  suffering  from 
illness. 

The  value  of  any  system  of  sickness  insurance,  how- 
ever, must  necessarily  be  judged  by  several  criteria. 

Criteria  of  Value  of  Insurance 
Is  the  adopted  system  one  which  is  equitable  in  its 
incidence  and  economical  in  its  administration;  and 
does  it  supply  maintenance  during  sickness  adequate 
for  the  needs  of  the  patient  and  his  family,  while  at 
the  same  time  offering  no  temptation  to  the  patient  to 
continue  on  the  sick  funds,  when  his  condition  no 
longer  necessitates  this? 

In  the  case  of  the  English  National  Insurance  Act, 
these  questions  unfortunately  cannot  be  answered  com- 
pletely in  the  affirmative. 

The  finance  of  the  Act  arranges  for  the  uniform 
contributions  (differing  for  each  sex)  from  some  thir- 
teen million  persons,  living  under  most  diverse  condi- 
tions, to  furnish  equal  benefits  (differing  for  each  sex) 
to  all  insured  persons,  irrespective  of  age,  locality,  or 
occupations ;  while  at  the  same  time  some  23,000  inde- 
pendent insurance  societies  continue  to  administer  the 
distribution  of  money  benefits,  each  with  its  own  segre- 


INSURANCE   AND    HEALTH  IO5 

gated  experience,  some  prosperous,  others  owing  to 
excessive  sickness  almost  bankrupt.  There  is  the  re- 
mote possibility  for  each  society  to  pay  additional 
benefits  if  justified  on  the  quinquennial  valuation. 

Substantially  men  and  women  have  been  placed  on 
a  similar  financial  basis.  The  sickness  of  pregnancy 
apparently  was  overlooked;  and  for  this  and  other 
reasons  the  insurance  funds  for  women  are  financially 
inadequate  for  the  benfits  promised. 

On  the  point  of  equity,  it  must  be  admitted  that  any 
system  of  so-called  insurance  which,  like  that  of  the 
English  Act,  excludes  a  large  proportion  of  the  popu- 
lation who,  while  paying  in  taxes  in  aid  of  the  insured, 
require  but  do  not  receive  their  benefits,  is  contrary 
to  the  principle  that  any  expenditure  of  Government 
funds  should  enure  to  the  whole  community  in  need 
of  the  provision  in  question. 

The  provision  of  10  shillings  a  week  for  incapacity 
lasting  26  weeks  (75.  6d  for  women),  followed  by  53. 
a  week  disablement  benefit,  although  inadequate  pro- 
vision for  family  maintenance  during  sickness  un- 
doubtedly is  helpful.  It  is  mischievous  when  in  con- 
sequence of  this  provision,  the  patient  is  tempted  to 
remain  at  home  under  unsatisfactory  domiciliary 
treatment,  instead  of  receiving  the  shorter  and  more 
successful  institutional  treatment,  which  should  have 
been  given. 

As  to  economy  of  administration,  I  can  speak  only 
with  reserve;  but  it  requires  little  imagination  to  ap- 


IO6  INSURANCE  AND   HEALTH 

preciate  that  the  numerous  migrations  of  wage- 
earners  imply  great  difficulties  in  book-keeping  as  well 
as  in  securing  insurance  medical  attendance,  and  that 
a  very  high  percentage  of  the  total  insurance  funds  is 
swallowed  up  in  elaborate  and  meticulous  account 
keeping. 

The  point  as  to  malingering  can  best  be  considered 
in  connection  with  a  discussion  of  the 

Medical  Benefit 

This  consists  of  such  medical  treatment,  at  home  or 
at  the  office  of  the  panel  doctor,*  as  "  can  consistently 
with  the  best  interests  of  the  patient  be  properly  un- 
dertaken by  a  practitioner  of  ordinary  professional 
competence  and  skill." 

The  Act  itself  promised  "adequate  medical  atten- 
dance and  treatment,"  but  under  regulations  this  has 
been  limited,  so  that  in  practice  it  means  chiefly  the 
treatment  only  of  minor  ailments.  Thus  (a)  there 
is  no  provision  for  hospital  treatment  of  patients 
needing  this,  except  the  Sanatorium  provision  for  tu- 
berculosis; (fc)  with  the  same  exception,  there  is  no 
provision  for  expert  services.  A  patient  requiring 
operative  treatment  for  fractures,  for  an  amputation,  or 
an  operation  for  appendicitis,  or  needing  treatment  for 
some  affection  of  the  eyes,  or  nose,  or  throat,  or  ears, 

*/.  e.,  any  doctor  in  a  given  area  who  is  willing  to  treat 
patients  under  the  conditions  of  the  Insurance  Act. 


INSURANCE  AND   HEALTH 

or  the  intravenous  treatment  of  syphilis  is  excluded 
from  medical  benefit.  So  likewise  are  dental  require- 
ments, (c)  There  is  no  provision  for  pathological 
diagnosis,  except  such  as  is  common  to  the  entire 
population,  and  no  X-ray  diagnosis,  except  possibly 
for  tuberculosis,  (d)  There  is  no  provision  for  nurs- 
ing assistance. 

In  view  of  the  unequal  distribution  and  insufficient 
provision  of  hospitals  for  the  general  population,  of 
their  inaccessibility  to  large  masses  of  patients,  and  of 
the  insufficiency  of  the  present  provision  for  the  scien- 
tific aid  to  treatment  which  modern  medicine  demands 
for  insured  and  non-insured  alike,  it  is  evident  that  the 
provision  for  medical  treatment  under  the  Act  is  un- 
satisfactory and  inadequate,  and  that  it  conduces  to 
prolonged  illness,  which  treatment  provided  on  more 
satisfactory  lines  would  avoid. 

To  state  adequately  the  defects  of  the  medical  pro- 
visions of  the  Insurance  Act  a  long  address  would  be 
required.  They  are,  however,  generally  well  known, 
and  their  existence  and  seriousness  is  admitted  by  all. 
(See  also  page  90.) 

It  is  necessary,  however,  to  say  more  on  the 

General  Practitioner  Treatment 
provided  under  the  Act.    Every  insured  person  is  al- 
lowed to  choose  his  own  doctor  within  a  given  distance. 
In  practice  very  few  patients  change  their  doctor  at  a 


108  INSURANCE  AND   HEALTH 

fixed  time  each  year  as  they  are  allowed  to  do ;  and  a 
considerable  proportion  of  insured  persons  do  not 
trouble  to  choose  a  doctor  at  all.  The  free  choice  of 
doctors  is  rather  a  sentimental  than  a  real  demand. 
The  panel  doctor  is  paid  an  annual  capitation  fee,  and 
hitherto  no  limit  has  been  placed  on  the  number  who 
may  place  themselves  on  his  roll.  The  domiciliary 
treatment  given  by  some  doctors  is  entirely  satisfac- 
tory within  the  limits  stated  above.  Commonly,  how- 
ever, it  is  as  unsatisfactory  as  the  "  club  practice " 
which  preceded  it,  and  against  which  the  British  Med- 
ical Association  inveighed.  It  involves  a  continuance 
of  the  mischievous  ideal  of  medical  practice  of  the 
past,  a  conception  still  held  by  a  large  portion  of  the 
public  to  its  own  detriment,  that  a  hasty  inquiry,  a 
perfunctory  examination,  and  a  bottle  of  medicine, 
represent  the  best  that  scientific  medicine  can  offer  a 
patient.  Had  there  been  organized  a  chain  of  medical 
services  for  all  needing  it,  including  consultations  and 
expert  assistance  when  needed,  every  patient  having 
the  right  to  call  for  these  when  dissatisfied  with  his 
panel  doctor,  including  also  hospital  provision  and 
nursing  as  required,  what  a  different  story  could  now 
be  told ! 

It  is  probable  that  some  at  least  of  these  additional 
services  will  be  added  gradually ;  but  it  must  be  noted 
that  the  present  payments  of  the  insured  will  not 
suffice  to  pay  for  them ;  and  that  if  they  are  to  be  pro- 


INSURANCE   AND    HEALTH  ICK) 

vided, — as  they  will  probably  need  to  be, — out  of 
public  funds,  the  general  public  are  in  equity  entitled 
to  these  services  even  though  they  are  not  insured. 

If  these  complete  services  were  provided,  the  med- 
ical treatment  now  provided  largely  at  the  expense  of 
the  community  could  be  made  a  means  for  advancing 
the  public  health.  This  it  can  not  at  present  claim  to 
be.  For  nothing  is  more  certain  than  that  the  prompt 
and  adequate  treatment  of  disease  curtails  its  dura- 
tion, diminishes  its  severity,  and  prevents  its  spread 
to  others. 

But  even  such  a  service  would  not  fulfil  its  complete 
possibilities  for  good  unless  it  were  joined  to  a  system 
of  hygienic  supervision  of  each  insured  person  and  of 
each  insured  person's  family,  this  system  being  organ- 
ically linked  up  with  the  wider  public  health  work  of 
the  larger  Public  Health  Authorities. 

The  chief  justification  of  a  national  system  of  insur- 
ance against  sickness  is  that  it  shall  be  an  active  auxil- 
iary in  the  prevention  of  disease.  At  present  it  is 
doubtful  whether  any  national  system  of  sickness  in- 
surance has  been  so.  It  has  only  been  so,  to  the  extent 
to  which  the  medical  treatment  of  the  masses  of  the 
population  has  been  improved  by  it ;  and  no  such  im- 
provement can  be  claimed  for  British  insurance.  The 
wider  possibilities  of  prevention  of  illness  and  eleva- 
tion of  the  general  standard  of  health,  by  making  each 
medical  practitioner  a  family  adviser  on  health  more 


HO  INSURANCE  AND   HEALTH 

than  a  practitioner  in  medicine,  have  not  been  realised 
or  even  brought  within  sight. 

Evils  of  the  Present  Medical  Benefit 

The  inadequacy  and  unscientific  character  of  the 
medical  treatment  given  to  insured  persons  are  asso- 
ciated with  a  large  amount  of  lax  certification  of  ill- 
ness, which  is  injurious  to  the  character  of  doctor  and 
patient,  besides  being  unfair  to  the  insurance  funds. 
Those  interested  in  this  point  should  read  paragraphs 
118,  119,  120,  121,  123,  125  of  the  Report  of  the  De- 
partmental Committee  on  Sickness  Benefit  Claims 
( Official  Report  Cd  7687). 

There  is  almost  universal  testimony  of  the  belief  (of  repre- 
sentatives of  friendly  societies)  that  medical  certificates  are 
granted  recklessly  (par.  119). 

Doctors  .  .  .  feel  a  difficulty  in  refusing  certificates  owing 
to  the  possible  effect  upon  their  practice.  ...  If  a  doctor  falls 
out  with  his  patient  he  loses  the  entire  family  (par.  120). 

These  statements  .  .  .  are  representative  of  an  enormous 
volume  of  dissatisfaction  with  the  action  of  the  medical  pro- 
fession. 

The  Committee  state: 

We  are  of  opinion  that  in  many  cases  doctors  have  given 
certificates  for  sickness  benefit  in  circumstances  in  which  these 
certificates  were  not  justified. 

From  the  standpoint  of  the  conscientious  practi- 
tioner the  present  position  is  profoundly  unsatisfac- 
tory. He  has  no  official  access  to  arrangements  for 


INSURANCE   AND    HEALTH  III 

consultative  and  expert  advice,  he  has  no  hospital  beds, 
no  skilled  nurses.  For  the  patient  the  position  is 
anomalous  and  leaves  him  with  but  a  fragment  of 
what  he  could  reasonably  expect  under  the  terms  of 
the  Act. 

Of  the  other  medical  benefit,  i.e.,  the  Sanatorium 
benefit  and  of  the  Maternity  benefit,  I  can  say  only  a 
few  words  here.  The  former  gives  the  insured  patient 
little  more  than  in  the  more  enlightened  sanitary  dis- 
tricts is  being  provided,  independently  of  insurance, 
by  Public  Health  Authorities.  It  would  have  been 
practicable  to  make  it  obligatory  on  all  Public  Health 
Authorities  to  provide  adequate  treatment  for  all  con- 
sumptive patients.  They  are  already  authorized  to  do 
this  under  Public  Health  Acts,  and  the  duty  could 
have  been,  and  can  still  be  made,  obligatory  by  regula- 
tion. And  in  that  case  the  connection  of  the  Sana- 
torium Benefit  with  the  National  (Health)  Insurance 
Act  would  happily  cease,  and  one  great  obstacle  to  a 
really  national  organization  against  tuberculosis  would 
disappear. 

The  Maternity  Benefit  provides  a  money  payment 
for  each  insured  woman  and  for  the  wife  of  each  in- 
sured man  on  the  birth  of  a  child.  The  money  pay- 
ment is  made  through  the  Insurance  Societies  uncon- 
ditionally, instead  of  being  made  a  means  of  securing 
that  the  birth  takes  place  under  circumstances  favour- 
able to  mother  and  infant.  During  recent  years  public 


112  INSURANCE   AND    HEALTH 

health  authorities  (aided  by  grants  from  the  Govern- 
ment of  one  half  of  the  total  approved  local  ex- 
penditure) have  been  making  medical  and  nursing 
provision  for  the  care  of  women  in  pregnancy,  in  par- 
turition, and  during  the  nursing  period,  on  a  rapidly 
increasing  scale,  the  grants  including  not  only  skilled 
assistance  but  also  domestic  aid  (home  helps)  in  suit- 
able cases.  There  can  be  no  question  that  increased 
provision  in  these  directions  will  have  a  more  generally 
beneficial  influence  than  money  payments,  and  should 
at  least  supplement  the  latter. 

To  sum  up,  if  the  national  English  system  of  insur- 
ance is  to  continue,  it  ought  in  my  view  to  be  shorn 
of  its  medical  functions  and  to  be  limited  to  money 
payments  during  sickness,  in  return  for  the  weekly 
contribution  made  by  employees  and  employers.  If  it 
be  thought  inadvisable  to  limit  the  State's  contribution, 
as  in  Germany,  to  what  is  spent  in  administration, 
then  in  equity  the  present  system  of  insurance  cannot 
continue  to  be  limited  to  those  now  participating  in  it. 

I  hold  strongly  that  the  State  should  embark  on  a 
much  larger  scale  than  at  present  on 

The  State  Treatment  of  Disease 
The  great  and  fundamental  mistake  made  in  the 
initiation  of  the  English  Insurance  Act  was  that  in 
effect  it  ignored  the  entire  history  of  the  relation  of 
preventive  and  curative  medicine  to  the  State.  This 
history  cannot  be  detailed  now:  but,  briefly,  for  long 


INSURANCE   AND   HEALTH  113 

years  the  destitute  had  been  entitled  to  domiciliary 
and  institutional  treatment  at  the  public  expense. 
This  medical  aid  was  given  by  Poor  Law  Authorities, 
and  their  method  of  doing  this  work  had  rendered  the 
benefaction  commonly  unacceptable.  Then  Public 
Health  Authorities  on  a  steadily  increasing  scale  found 
it  necessary  to  treat  disease  in  order  the  more  effec- 
tively to  prevent  it.  And  so  fevers  and  smallpox,  and 
chronic  infective  diseases  like  tuberculosis  and  syphilis 
came  under  treatment,  practically  for  all  comers,  at 
the  public  expense.  As  already  mentioned  the  funda- 
mental importance  of  maternity  and  childhood  has  also 
been  realised,  and  the  State  is  now  taking  an  increas- 
ing share  in  ensuring  health  at  these  periods  of  life. 
And  while  Public  Health  Authorities  were  increasing 
their  activities,  Education  Authorities  began  to  sub- 
ject school  children  to  medical  inspection,  and  to 
treat  them  for  the  detected  defects,  the  treatment 
of  which  they  could  not  otherwise  secure.  And  so, 
not  to  make  this  sketch  too  complex,  three  great  cen- 
tral government  departments  or  sub-departments  and 
three  sets  of  local  authorities  were  engaged  in  medi- 
cally treating  the  people  at  the  public  expense.  This 
sketch  does  not  include  the  smaller  (nevertheless 
enormous)  amount  of  treatment  of  disease  by  volun- 
tary hospitals.  It  is  safe  to  state  that  at  any  one  time 
one-half  of  the  total  treatment  of  disease  is  being  car- 
ried out  at  the  public  expense.  If  the  domiciliary 


114  INSURANCE   AND    HEALTH 

treatment  of  insured  persons  is  worthy  to  come  into 
the  same  category  as  the  skilled  services  mentioned 
above,  the  proportion  of  disease  already  treated  at  the 
public  expense  greatly  exceeds  50  per  cent.  (Note. — 
Less  than  four-ninths  of  the  cost  of  medical  treatment 
of  insured  persons  comes  from  the  contributions  of 
the  insured.) 

The  complexity  of  local  authorities  concerned  in  the 
treatment  of  disease  was  wilfully  increased  under  the 
National  (Health)  Insurance  Act;  and,  contrary  to 
the  advice  of  public  health  workers  and  of  the  Royal 
Commission  on  the  Poor  Laws  a  golden  opportunity 
for  securing  the  merging  of  poor  law  into  public  health 
work  and  for  initiating  a  unified  system  of  State  Medi- 
cine for  all  who  need  it  was  lost. 

Poverty  to  a  preponderant  extent  is  due  to  sickness 
Two  statements  have  recently  been  made  by  the  Med- 
ical Society  of  the  State  of  New  York,  viz.,  that  "  evi- 
dence is  against  the  fact  that  any  considerable  amount 
of  impoverishment  is  caused  by  illness,"  and  that  they 
can  find  no  "  available  evidence  that  ...  in  the  main, 
medical  attendance  in  this  State  is  grossly  deficient  in 
quantity  or  grossly  defective  in  quality."  (Monthly 
Labor  Review,  January,  1920,  p.  256.) 

One  can  admire  the  optimism,  while  denying  the  ac- 
curacy of  the  first  statement :  of  the  second  statement, 
as  it  refers  to  the  State  of  New  York,  I  can  say 
nothing,  except  that  a  statement  identical  with  the  one 


INSURANCE   AND    HEALTH  115 

denied  above  would  be  literally  true  for  England.  In 
1907  I  wrote,  "  the  coexistent  but  uncoordinated  sys- 
tems of  treatment  of  disease  have  failed  lamentably 
to  provide  what  the  health  of  the  community  requires 
— means  for  ensuring  effectively  the  early  recognition 
and  proper  treatment  of  all  disease  "  (British  Medical 
Journal,  Sept.  14,  '07).  That  remains  broadly  true, 
and  no  remedy  will  suffice  which  does  not  ensure  for 
every  member  of  the  community  in  essential  par- 
ticulars as  good  treatment  as  the  most  favored  now 
possess. 

The  socialization  of  medicine  has  gone  too  far,  its 
beneficent  effects  are  becoming  too  well  appreciated, 
to  render  it  possible,  even  were  it  not  undesirable  and 
mischievous,  to  hinder  its  further  extension.  We  have 
travelled  more  than  half  the  road  towards  the  goal  of 
general  provision  of  skilled  medical  assistance  by  co- 
operative means,  i.e.,  out  of  the  communal  purse.  If 
this  is  desirable  for  elementary  general  education,  it 
is  even  more  important  when  the  aim  is  the  restoration 
and  the  maintenance  of  the  highest  attainable  level  of 
health  for  each  member  of  the  community,  who  is 
willing  to  share  in  the  offered  benefits.  If  we  include 
the  third  of  the  total  population  who  now  receive  in 
Great  Britain  the  unsatisfactory  medical  benefit  under 
the  National  (Health)  Insurance  Act,  and  remember 
the  rapidly  increasing  scope  of  voluntary  and  official  in- 
stitutional treatment  of  disease,  hesitation  in  accepting 


Il6  INSURANCE  AND   HEALTH 

the  inevitable  should  be  replaced  by  a  determination 
to  guide  future  developments  and  to  render  them  effi- 
cient and  economical.  What  is  good  for  the  public  is 
good  also  for  the  members  of  the  medical  profession. 

If  asked  to  advise  on  the  steps  which  it  is  advisable 
to  take  in  regard  to  Sickness  Insurance  in  a  community 
which  has  not  adopted  a  scheme,  I  should  emphasise 
the  prior  necessity  for  the  State  to  secure  a  completely 
satisfactory  system  of  public  medical  care  before  en- 
gaging in  the  more  difficult  task  of  providing  monetary 
payments  in  sickness.  It  is  well  to  bear  in  mind  that 
medical  attendance  is  a  form  of  communal  assistance 
the  demand  for  which  does  not  tend  to  increase  with 
the  supply;  whereas  monetary  benefits  have  always 
shown  this  trend,  as  demonstrated  by  the  experience 
of  both  Friendly  Societies  and  charitable  agencies. 
As  satisfactory  administration  of  monetary  benefits 
during  sickness  depends  on  securing  medical  certifica- 
tion which  is  above  suspicion,  it  is  fundamentally  im- 
portant that  under  any  method  of  public  medical 
attendance  the  certification  (for  incapacity  to  work) 
should  be  completely  independent  of  any  coexistent 
system  of  sickness  insurance. 

A  completely  efficient  public  medical  service,  if  pre- 
ventive as  well  as  curative,  will  diminish  greatly  the 
monetary  calls  on  sickness  insurance  and  lower  its 
expense.  Let  me  briefly  enumerate  the  conditions 
which  such  a  medical  service  must  fulfil : 


INSURANCE   AND    HEALTH  117 

1.  It  must  possess  facilities  for  consultations  with 
physicians   and   surgeons   having  special  knowledge, 
equalling  in  efficiency  those  possessed  by  the  well-to-do. 

2.  All  modern  pathological  and   physical   aids  to 
diagnosis  and  treatment  must  be  available. 

3.  Hospital  treatment  must  be  secured  for  all  whose 
illness  cannot  be  satisfactorily  treated  at  home. 

4.  In  the  ordinary  treatment  of  patients  by  medical 
practitioners  there  must  be  provision  for  team  work, 
as  for  instance  at  local  dispensaries,  so  that  a  patient 
may,  where  this  is  desirable  be  conveniently  examined 
by  several  doctors.     (Group  medicine.) 

5.  Skilled  nursing  must  be  obtainable  for  patients 
needing  to  be  treated  at  home,  though  the  extent  to 
which  this  is  required  will  be  greatly  reduced  by  in- 
creased use  of  hospital  beds. 

6.  In  every  district  the  patient  might  have  the  choice 
between  several  doctors;  but  unnecessary  change  of 
doctors   should  be   discouraged.     Subject  to  general 
regulations,  however,  he  should  be  entitled  to  demand 
a  consultation  when  not  satisfied  as  to  his  treatment. 

7.  The  doctor  chosen  by  the  head  of  the  family 
should  be  held  responsible  for  supervising  the  health 
of  the  whole  family ;  and  should  be  required  at  least 
once  in  three  months  to  arrange  to  see  each  member 
of  it,  to  ascertain  any  existing  disease,  or  any  habits, 
manner  of  life  or  work  tending  to  cause  disease,  and 
to  make  a  concise  statement  to  the  medical  officer  of 


Il8  INSURANCE   AND    HEALTH 

health  or  health  commissioner  embodying  his  recom- 
mendations as  to  any  public  health  action  which  may 
be  needed. 

8.  The  scheme  at  first  might  be  limited  to  one  sec- 
tion of  the  population,  but  there  is  no  reason  why  ulti- 
mately it  should  not  embrace  all  willing  to  join  it. 

9.  The  remuneration  of  doctors  engaging  in  this 
public  work  should  be  adequate  at  once  to  attract  ju- 
nior members  of  the  profession.    The  remuneration 
should  not  be  on  a  capitation  basis,  but  by  salary, 
modified    according   to   the   success    achieved.     The 
scheme  would  enable  doctors  to  have  ample  leisure 
and  holidays  and  to  take  part  in  post-graduate  courses. 
Every  inducement  should  be  given  to  physicians  to 
undertake  along  with  their  family  work  special  work 
in  connection  with  one  of  the  following  activities : 

Pathological  laboratories, 

Hospitals, 

Health  centres  for  infants  and  mothers, 

Prenatal  and  post-natal  clinics, 

Consultant  obstetric  work, 

Pre-school  clinics. 

School  medical  inspection  and  clinics, 

Industrial  inspections  and  clinics,  etc. 

10.  Medical  schemes  on  the  above  general  lines  can 
only  be  completely  satisfactory  to  the  extent  to  which 
every  physician  taking  part  in  them  becomes  imbued 
with  an  appreciation  of  the  almost  unlimited  pre- 


INSURANCE   AND   HEALTH  119 

ventive  possibilities  opened  up  by  the  opportunity  to 
treat  disease,  and  by  the  realization  likewise  that  an 
essential  part  of  his  family  work  should  consist  in 
detecting  the  beginnings  of  disease  and  in  detecting 
and  securing  the  removal  of  domestic,  dietetic,  hous- 
ing, industrial  or  other  factors  liable  to  cause  disease. 
If  these  ideals  can  be  even  partially  realised,  we 
shall  have  approached  the  time  when  every  practising 
physician  will  become  a  hygienist,  and  when  any  sick- 
ness insurance  still  demanded  or  required  will  be  on  a 
scale  much  lower  than  is  necessary  at  the  present  time. 
In  short,  compulsory  sickness  insurance  under  present 
conditions  is  a  measure  of  relief.  It  has  almost  as 
little  prevention  involved  in  it,  as  has  insurance  against 
the  risk  of  fire.  Relief  must  be  given,  by  insurance  or 
otherwise.  How  much  preferable,  however,  it  would 
be  to  precede  it  by  a  far-reaching  scheme  of  effective 
preventive  and  curative  work,  or  at  the  least  to  place 
it  in  a  strictly  subsidiary  position  to  such  a  scheme  in 
actual  operation ! 


CHAPTER  V 

SOME  PROBLEMS  OF  PREVENTIVE  MEDICINE  OF  THE 
IMMEDIATE  FUTURE* 

The  Great  War  has  changed  our  outlook  on  social, 
including  medical,  problems;  and  has  made  all  of  us 
consider  anxiously  in  the  midst  of  the  terrible  wreck- 
age from  war,  what  useful  lessons  may  be  garnered 
for  our  future  guidance.  In  speaking  of  losses,  I  am 
not  referring  to  financial  burdens,  though  these  are 
fabulously  high — the  bare  statement  that  the  British 
national  debt  has  increased  from  645  to  near  8,000 
millions  sterling,  brings  this  home — and  we  shall, 
most  of  us,  go  relatively  poor  for  the  rest  of  our  lives 
and  our  children  likewise.  Nothing  but  the  most 
effective  and  scientific  use  of  our  energies  on  the  part 
of  workers  of  every  class  can  save  us  from  protracted 
poverty. 

I  am  thinking  rather,  however,  of  the  losses  of  life 
and  limb,  of  hearing  and  eyesight,  and  of  reason,  which 
have  been  experienced — one  or  other — in  nearly  every 
other  family  in  the  British  Empire,  and  which  show 
once  more  the  wantonness  of  war:  how  cheaply  life 

1  An  address  to  the  Academy  of  Medicine,  Toronto,  June 
20,  1919. 

120 


OF   THE    IMMEDIATE   FUTURE  121 

is  held  by  it,  how  careless  it  is  of  the  individual ;  and 
how  disregardful  it  is  of  human  promise  and  per- 
formance. 

The  destruction  of  over  700,000  lives  of  sharers  in 
our  common  Empire,  killed  in  battle  or  dead  from 
wounds,  represents  an  imperial  loss,  a  terrible  de- 
struction of  the  real  capital  of  the  Empire — its  man- 
hood— and  of  the  flower  of  that  manhood;  and  gen- 
erations will  come  and  go  before  the  Empire  recovers 
completely. 

Gains  from  War 

But  we  can  set  out  some  great  gains  from  war. 

i.  Not  the  least  of  these  is  the  fact  that  the  fears 
entertained  by  the  more  pessimistic  that  we  had  be- 
come enervated  and  decadent  have  been  falsified  on 
many  a  stricken  field ;  and  not  less  in  the  strenuous 
work  of  those  who  have  worked  remote  from  the  bat- 
tlefield. Our  men  and  many  women  also  have  shown 
themselves  willing  to  give  their  lives  for  great  imper- 
sonal ends.  Their  lives  have  been  sacrificed — for  our 
children,  for  liberty,  for  peace,  for  security  against 
military  barbarism,  and  for  high  ideals  of  life.  The 
emergence  of  such  a  high  proportion  of  our  total  popu- 
lation from  selfishness  and  self-centred  life  to  a  sacri- 
ficial position,  raises  hope  that  rightly  directed  appeal 
to  the  collective  self  of  the  community  during  peace 
time  for  aid  against  the  horrors  of  peace — especially 


122        SOME   PROBLEMS   OF   PREVENTIVE    MEDICINE 

those  caused  by  disease — will  also  succeed  in  enlisting 
the  assistance  of  the  majority  of  the  population  and 
thus  removing  the  vast  mass  of  removable  disease  and 
disablement  which  now  prevails. 

2.  The  war  has  knitted  together  in  active  comrade- 
ship the  Old  Country  and  its  younger  and  more  ener- 
getic children  in  the  Dominion  of  Canada  and  in  other 
parts  of  the  British  Empire,  in  bonds  of  mutual  indebt- 
edness and  gratitude  and  in  admiration  of  great  deeds, 
in  a  manner  and  to  an  extent  which  must  forever  pre- 
clude misunderstanding  or  separation. 

In  these  two  respects  especially — and  in  others  which 
I  shall  dwell  on  more  fully — we  can,  as  Wordsworth 
put  it,  when  commenting  on  the  wars  of  the  French 
Revolutionary  period : 

Though  doomed  to  go  in  company  with  Pain, 
And  Fear  and  Bloodshed,  miserable  train ! 
Turn  our  necessity  to  glorious  gain. 

The  Work  of  Women 

3.  The  war  has  revealed  to  us  the  great  extent  to 
which  women  in  emergencies  can  replace  men.     I  need 
not  repeat  the  story  of  how  women  in  a  few  months 
mastered  mechanical  intricacies  in  munition  works,  for 
which  previously  a  long  training  was  thought  neces- 
sary; nor  how  educated  women  after  a  few  months' 
intensive  training  were  able,  under  war  conditions,  to 
undertake  the  work  of  fully  trained  nurses.     We  can- 


OF   THE   IMMEDIATE   FUTURE  123 

not  ignore  these  facts ;  and  in  regard  to  nursing,  they 
should  lead  us  to  consider  whether,  under  modern  con- 
ditions of  life,  it  is  necessary  that  the  great  body  of 
nurses,  like  the  great  majority  of  medical  practitioners, 
need  to  be  experts  in  major  operations,  and  whether 
they  should  not  be  trained  chiefly  from  the  standpoint 
of  the  ordinary  illnesses  of  the  household.  Particu- 
larly, it  is  important  to  recognize  that  the  training  of<| 
the  health  visitor  or  public  health  nurse  must  diverge 
at  an  early  period  of  training  from  that  of  the  clinical 
nurse. 

In  another  direction  women  are  about  to  influence 
vitally  the  problems  of  public  health  in  the  near  future. 
The  municipal  and  parliamentary  vote  has  been  given 
to  women  in  England,  and  is  not  likely  long  to  be 
withheld  here.  How  will  they  use  it?  When  they 
use  it  will  "  politics  "  be  a  name  for  a  contemptible 
thing  as  it  has  become  in  some  towns  and  states,  or 
will  women  insist  on  clean  administration  and  efficient  \ 
work  to  secure  the  health  and  welfare  of  the  com- 
munity ? 

Prohibition  of  Alcoholic  Drinks 

4.  The  prohibition  law  against  alcoholic  drinks  in 
the  U.  S.  A.  is  largely  the  work  of  American  women. 
Whatever  view  be  taken  of  this  law — and  I  regard  it 
as  one  of  the  most  significant  social  events  of  the  age 
— let  there  be  no  doubt  as  to  the  essential  facts  of  the 
problem. 


124       SOME    PROBLEMS   OF   PREVENTIVE    MEDICINE 

Alcoholism  is  a  potent  enemy  of  the  race.  It  is  a 
great  creator  of  avoidable  poverty.  It  makes  the  bed 
ready  for  tuberculosis.  It  is  a  frequent  excitant  of 
exposure  to  the  infection  of  venereal  diseases ;  it  swells 
the  ranks  of  fatherless  children,  and  of  neglected  in- 
fants; it  helps  to  fill  our  prisons  and  our  hospitals. 
Let  it  be  admitted,  if  you  like,  that  light  wines  and 
beers  are  pleasant,  and  in  strict  moderation  with  meals 
are  beverages  to  which  little  or  no  harm  can  be  traced ; 
but  heavier  drinks  and  all  non-medicinal  spirit  drink- 
ing are  to  be  condemned ;  and  the  country  which  dis- 
tinguishes itself  by  abolishing  these  drinks  will,  other 
things  being  equal,  in  my  opinion,  inevitably  attain 
quickly  an  industrial  and  economic  superiority  over  all 
countries  which  continue  to  follow  the  older  ways. 

5.  A  great  gain  during  the  war  is  constituted  by  the 
fact  that  science  has  come  into  its  own.  The  war  has 
been  described  as  a  war  of  engineers.  Its  chief  suc- 
cesses have  been  won  largely  by  applied  science ;  and 
it  is  gratifying  to  record  that  the  Anglo-Saxon  intel- 
lectuals, when  their  services  have  been  engaged,  have 
proved  themselves  more  than  equal  to  the  German 
scientist,  whether  in  physics  or  chemistry  or  medicine. 

The  facts  as  to  the  wonderful  extent  to  which  dis- 
ease has  been  prevented  during  this  war  need  not  be 
detailed.  Intestinal  diseases  have  been  kept  strictly 
under  control.  In  no  previous  war  has  smallpox  or 
typhoid  fever  claimed  so  small  a  toll  on  the  belligerents. 


OF  THE   IMMEDIATE    FUTURE  125 

Malaria,  it  is  true,  has  claimed  many  victims,,  owing 
to  our  soldiers  having  to  operate  in  countries  in  which 
the  needed  precautions  could  not  be  completely  carried 
out.  Typhus  has  scarcely  claimed  a  victim  among  the 
British  forces,  and  although  trench  fever  was  common, 
medical  discovery,  by  showing  its  relationship  to  the 
bite  of  the  louse,  has  placed  within  reach  an  imme- 
diately practicable  means  for  avoiding  this  serious 
cause  of  military  disablement. 

Three  sets  of  diseases  have  not  been  successfully 
combatted  during  the  war — the  group  of  respiratory 
affections,  tuberculosis,  and  venereal  diseases,  and  on 
each  of  these  it  is  desirable  to  make  a  few  remarks. 

Respiratory  Diseases 

6.  In  the  group  of  respiratory  diseases  I  think  we 
should  include  a  number  of  diseases  not  commonly 
regarded  as  such,  but  in  which,  so  far  as  can  be  judged, 
infection  is  received  by  inhalation ;  and  I  would,  there- 
fore, group  together  such  miscellaneous  diseases  as 
poliomyelitis,  cerebro-spinal  fever,  measles,  bronchitis, 
pneumonia,  and  influenza.  All  agree  in  one  particu- 
lar, that  attempted  preventive  measures  against  their 
spread  are  dubious  in  effect.  These  diseases  naturally 
divide  themselves  into  two  groups :  the  first  compris- 
ing measles  and  influenza,  both  of  which  spread — 
when,  as  in  influenza,  the  almost  unknown  conditions 
determining  spread  are  present — to  an  extent  only 


126       SOME   PROBLEMS   OF   PREVENTIVE    MEDICINE 

limited  by  the  failure  of  susceptible  persons;  and  the 
second  comprising  the  other  diseases  already  enum- 
erated, of  the  conditions  determining  attack  from 
which  we  are  profoundly  ignorant.  We  do  know, 
however,  concerning  cerebro-spinal  fever  and  measles, 
that  they  spread  more  easily  and  become  more  severe 
under  conditions  of  massive  overcrowding;  and  their 
unusual  severity  in  war  is  thus  partially  explained. 
Beyond  this  obvious  indication  for  prevention  we  can 
do  but  little. 

It  may,  however,  be  mentioned,  that  in  England 
during  the  last  few  years,  we  have  determined  that 
our  lack  of  ability  to  prevent  outbreaks  of  measles 
shall  not  prevent  us  from  attempts  to  diminish  their 
fatality,  and  the  notification  of  this  disease  has  there- 
fore been  enforced,  as  a  necessary  preliminary  to 
prompt  and  fairly  complete  action,  and  local  authori- 
ties have  been  urged  to  provide  nurses  to  assist  in  the 
domiciliary  nursing  of  cases  of  measles.  Grants  of 
half  the  expenditure  expended  in  nursing  this  and 
some  other  children's  diseases  are  paid  by  the  Central 
Government.  If  the  spread  of  infection  cannot  be 
stayed,  it  is  our  duty  to  diminish  the  loss  of  life 
by  providing  nursing  assistance  whenever  required. 
This  provision  of  nursing  assistance  in  a  number  of 
children's  and  maternal  illnesses,  half  the  expenditure 
being  paid  from  Central  and  half  from  local  funds, 
will,  I  trust,  soon  be  followed  by  a  general  provision 
of  nursing  assistance  from  public  funds. 


OF  THE   IMMEDIATE   FUTURE  127 

The  recent  epidemic  of.. influenza  has  taught  us  sev- 
eral important  lessons — First,  we  have  been  painfully 
reminded  that  we  are  completely  ignorant  of  the  causes 
of  the  pandemic  waves  of  this  terrible  disease,  which, 
at  irregular  intervals  of  years,  traverse  the  world.  We 
may  surmise  that  the  crowding  and  the  mental  and 
physical  depression  of  war  caused  increased  rapidity 
of  spread  and  a  greater  fatality  in  the  present  out- 
break; but  influenza  has  spread  and  been  only  less 
fatal  than  in  the  present  outbreak  when  there  was  no 
war,  and  we  must  admit  our  ignorance  of  the  cause 
of  this. 

Numerous  investigators  in  many  lands  have  been 
striving  to  illumine  our  ignorance;  but  until  success 
crowns  their  efforts,  it  is  well  to  admit  that  on  the 
large  scale  all  attempts  to  prevent  the  spread  of  in- 
fluenza have  failed. 

But,  in  this  disease,  as  in  measles,  this  failure  in 
prevention  is  no  reason  for  refraining  from  every  pos- 
sible effort  to  restrain  death.  In  every  country  and  in 
nearly  every  invaded  district,  many  sick  were  unable 
to  obtain  adequate  nursing  and  other  domestic  care. 
Here  and  there  organized  mobile  team  work  partially 
overcame  the  difficulty;  but  the  one  lesson  which 
emerges  from  this  great  pandemic  is  the  necessity  for 
having  in  every  area  a  large  nursing  reserve.  Here  is 
one  of  many  spheres  of  utility,  which  should,  I  think, 
be  occupied  by  Red  Cross  workers,  who  have  done 
such  admirable  work  during  the  Great  War. 


128       SOME    PROBLEMS   OF   PREVENTIVE    MEDICINE 

Many  of  these  Red  Cross  workers  were  not  fully 
trained  before  the  war,  but  intelligent  workers  under 
stress  of  circumstances  showed  themselves  competent 
in  many  instances  to  undertake  highly  skilled  work; 
while  a  much  larger  number  under  the  supervision  of 
more  fully  trained  nurses  and  doctors  were  able  to 
carry  out  satisfactorily  the  routine  but  still  extremely 
important  work,  of  ordinary  nursing.  During  the  in- 
fluenza outbreak  many  such  "  Nursing  Aids "  did 
admirable  work,  and  the  epidemic  has  demonstrated 
once  for  all  the  absolute  necessity  of  having  available 
a  large  number  of  such  nursing  aids.  Cannot  these 
be  employed  on  a  large  scale  when  no  epidemic  is 
raging?  Is  it  necessary  for  every  case  of  sickness 
that  a  fully-trained  nurse  should  be  engaged  ?  Would 
not  the  physician  be  equally  satisfied  in  a  large  pro- 
portion of  his  cases,  if  he  had  available  a  less  elabo- 
rately trained  assistant,  who  understood  personal  hy- 
giene thoroughly,  who  could  give  an  enema,  could  take 
temperatures,  and  would  follow  instructions  implicitly 
and  intelligently? 

Incidentally  I  consider  that  some  such  modified  and 
simplified  training  in  actual  nursing  would  form  an 
adequate  background  for  the  special  training  required 
to  obtain  a  competent  school  nurse,  tuberculosis  nurse, 
or  public  health  nurse  (health  visitor)  ;  and  that  under 
present  conditions  a  three  years'  training  as  a  nurse  is 
not  the  best  foundation  on  which  to  build  the  special 
training  required  for  these  public  health  nurses. 


OF   THE   IMMEDIATE   FUTURE  I2Q 

Tuberculosis 

7.  A  serious  penalty  of  war  conditions  has  been  the 
increase  of  tuberculosis.  It  is  not  surprising  that  the 
crowding  in  barracks,  the  overwork  and  overstrain, 
the  dirtier  habits,  and  risks  from  expectoration  in 
massed  communities,  should  have  increased  tubercu- 
losis among  soldiers ;  both  by  activating  latent  tuber- 
culosis and  by  introducing  new  infection.  Nor  is  it 
surprising  that  under  analogous  conditions  tubercu- 
losis has  increased  among  women,  especially  at  the 
ages  in  which  the  enormous  increase  in  their  industrial 
employment  has  taken  place. 

The  national  anti-tuberculosis  arrangements  which 
were  made  in  connection  with  the  National  Insurance 
Act  had  scarcely  been  fully  organized  when  the  war 
began.  At  an  early  stage  it  had  become  plain  that  in 
essentials  non-insured  must  be  provided  for  as  well 
as  insured,  and  Government  grants  of  half  the  ap- 
proved expenditure  on  the  treatment  of  tuberculosis 
in  the  general  population  endorsed  this  principle. 
There  was  no  reason,  therefore,  for  the  continued 
separate  existence  of  the  "  Sanatorium  Benefit " ;  and 
had  it  not  been  for  political  considerations  the  treat- 
ment of  tuberculosis  would  probably  already  have  been 
handed  over  to  public  health  authorities,  while  leaving 
intact  the  general  provisions  of  the  National  Insurance 
Act  as  to  monetary  payments  and  benefits.  The  same 
transference  should  apply  also  to  the  treatment  of  any 
10 


I3O       SOME   PROBLEMS   OF  PREVENTIVE   MEDICINE 

disease  undertaken  at  the  public  expense.  The  treat- 
ment of  disease,  especially  in  its  more  difficult  special- 
ist and  institutional  branches,  should  become  a  matter 
of  communal  provision,  to  which  every  person  would 
be  entitled  as  he  is  to  the  common  provision  under  our 
system  of  elementary  education,  or  to  the  common  use 
of  free  libraries  and  of  drinking  water. 

There  is  needed  a  widely  extended  propaganda 
against  tuberculosis.  The  public  as  well  as  the  med- 
ical profession  need  to  be  educated,  the  latter  in  the 
carrying  out  of  complete  and  prompt  notification  of 
cases  of  the  disease,  and  in  the  use  of  all  facilities  pro- 
vided for  aiding  diagnosis ;  the  former  in  the  risks  of 
industrial  and  other  dust  infections,  of  indiscriminate 
expectoration,  of  alcoholism,  of  imperfect  nutrition, 
of  bad  housing,  and  so  on.  We  all  need  to  learn  the 
folly  of  imperfect  measures  against  tuberculosis.  Com- 
plete success  can  only  be  attained  if  we  assume  re- 
sponsibility for  the  whole  course  of  the  life  of  the 
consumptive.  Not  only  must  educational  sanatoria 
be  provided — and,  still  more  important — hospital  treat- 
ment for  all  the  emergencies  of  the  disease  and  in 
advanced  disease ;  but  in  the  quiescent  intervals  assist- 
ance must  be  forthcoming  to  cover  the  margin  between 
a  living  wage  and  the  earning  capacity  of  the  ex- 
patient,  and  economic  assistance  must  be  provided  for 
protecting  the  patient,  and  still  more  his  family,  from 
defective  nutrition  and  from  infection.  To  stop  short 


OF  THE   IMMEDIATE   FUTURE  13! 

of  this  is  to  be  extravagantly  parsimonious ;  to  do  this 
is  to  economize  in  sickness  and  to  secure  increased 
efficiency  in  future  generations.  What  better  work 
can  be  thought  of  for  Red  Cross  volunteers  than  in 
supplementing  the  work  already  carried  out  by  anti- 
tuberculosis  organizations  and  in  extending  and  sys- 
tematizing these  agencies.  Is  not  such  peace  work 
equal  in  importance  with  the  war  work  which  Red 
Cross  workers  have  already  accomplished? 

Venereal  Diseases 

8.  Venus  and  Mars  are  always  closely  associated, 
and  it  is  a  lamentable  fact  that  one  heritage  of  the  war 
will  be  a  great  increase  of  venereal  diseases  in  our 
midst.  In  England  we  had  become  thoroughly  aroused 
to  the  magnitude  of  this  evil  even  in  peace  time.  The 
report  of  the  Royal  Commission  on  Venereal  Diseases 
and  the  propaganda  since  actively  carried  out,  have 
led  to  the  taking  of  measures  which  I  can  only  briefly 
enumerate.  The  duty  has  been  imposed  on  every 
county  and  county  borough  council  of  providing  aids 
to  pathological  diagnosis,  and  of  providing  clinics  for 
the  treatment  of  these  diseases  for  all  comers,  irre- 
spective of  residential  or  monetary  conditions.  These 
clinics  have  been  generally  started  throughout  the 
country,  and  their  use  has  been  widely  advertised  and 
encouraged  by  propaganda  in  the  form  of  lectures  and 
addresses  in  factories  and  to  various  social  groups, 


132       SOME   PROBLEMS  OF  PREVENTIVE   MEDICINE 

and  by  public  advertisement.  In  addition  an  enact- 
ment has  been  secured  absolutely  prohibiting  the  treat- 
ment of  venereal  diseases  except  by  qualified  medical 
practitioners,  and  prohibiting  the  advertising  or  offer- 
ing for  sale  of  any  remedy  for  venereal  diseases.  In 
addition,  arsenobenzol  preparations  are  supplied  to 
medical  practitioners  who  have  experience  in  their  use 
for  their  own  patients. 

These  measures  do  not  cover  the  entire  ground. 
The  enforcement  of  police  regulations  against  vice,  the 
detention  of  infectious  persons  who  cannot  be  trusted 
to  refrain  from  spreading  disease,  the  raising  of  the 
general  standard  of  sexual  morality — until  public  opin- 
ion demands  that  it  shall  be  as  high  for  men  as  for 
women — are  among  the  reforms  which  are  called  for. 

In  encouraging  social  reform  in  these  directions  Red 
Cross  workers  have  a  most  fruitful  field  of  work,  and 
they  can  render  invaluable  assistance  in  removing  a 
canker  which  at  present  eats  into  the  vitals  of  the 
community,  and  is  responsible  for  untold  suffering  in 
women  and  children,  for  premature  old  age  and  paral- 
ysis in  men,  and  for  a  large  share  of  the  total  inmates 
of  our  lunatic  asylums. 

The  Mother  and  the  Child 

9.  I  have  left  myself  but  scant  time  to  speak  of 
what  is  at  once  a  chief  lesson  of  the  war  and  the 
most  pressing  problem  in  the  preventive  medicine  of 


OF  THE   IMMEDIATE   FUTURE  133 

the  immediate  future.  I  refer  to  the  need  for  more 
complete  protection  of  motherhood  and  childhood 
against  the  dangers  besetting  them. 

It  would  be  a  mistake  to  assume  that  only  since  war 
began  have  efforts  both  by  sanitary  authorities  and  by 
voluntary  agencies  been  made  on  a  large  scale  to  di- 
minish infantile  and  maternal  mortality.  But  during 
the  war,  and  since  it  terminated,  these  efforts  have 
been  redoubled  and  are  becoming  universal ;  and  there 
is  opening  out  a  prospect  of  safe  maternity  for  mothers 
and  of  protected  infancy  for  all  newcomers  on  the 
stage  of  life.  If  only  we  are  prepared  to  do  what  is 
almost  immediately  practicable  for  this  end,  death  or 
injury  associated  with  child-bearing  will  become  rare, 
the  loss  of  infant  and  child  life  will  be  halved,  and 
what  is  still  more  important,  mothers  and  infants  will 
cease  to  be  damaged  by  neglect  or  ignorance  at  critical 
periods  of  their  life,  and  will  not  become  burdens  to 
themselves  and  to  the  community. 

This  is  no  visionary  dream.  Past  experience  shows 
that  it  is  within  reach.  What  other  interpretations 
can  be  placed  on  the  facts  revealed  in  official  reports  ? 

I  am  unable  to  quote  Canadian  figures ;  but  I  am 
justified  in  assuming  that  differences  similar  to  these 
I  am  about  to  quote  from  my  own  reports  exist  also 
here.  The  average  number  of  deaths  of  mothers  from 
complications  arising  during  pregnancy,  and  at  or 
after  confinement,  are  one  maternal  death  for  every 


134       SOME   PROBLEMS  OF  PREVENTIVE   MEDICINE 

250  infants  born  alive.  In  some  parts  of  England 
instead  of  four  mothers,  six  or  even  eight  or  nine 
mothers  die  for  every  thousand  infants  born.  There 
are  marked  differences  in  maternal  mortality  in  neigh- 
bouring towns  and  districts;  and  the  only  conclusion 
which  fits  in  with  the  facts  is  that,  in  many  parts  of 
the  country,  the  arrangements  for  medical  attendance 
on  mothers  at  and  before  their  confinement  are  inade- 
quate or  deficient  in  quality  or  both. 

The  Maternity  Benefit  under  the  National  Insurance 
Act,  though  a  valuable  evidence  of  the  interest  of  the 
State  in  maternity,  has  not  provided  a  sufficient  rem- 
edy. It  was  an  unconditional  benefit  limited  to  in- 
sured women  or  the  wives  of  insured  men,  and  there 
was  no  guarantee  that  the  money  allotted  would  be 
utilized  in  supplying  the  medical,  midwifery,  or  nurs- 
ing assistance  needed  by  the  patient,  or  in  relieving 
her  from  domestic  duties  which  she  is  unfit  to  per- 
form. It  was  furthermore,  inadequate  for  these  pur- 
poses. We  should  not  think  of  handing  over  to  each 
individual  householder  an  annual  sum  of  money,  ad- 
vising him  to  expend  it  on  a  supply  of  books  or  in  the 
education  of  his  children.  It  is  more  economical  and 
more  effective  to  provide  free  libraries  and  public  ele- 
mentary schools  without  payment  of  fees.  Is  not 
similar  action  important  in  connection  with  child- 
bearing,  on  which  the  continuity  of  family  life  and 
civilization  depends  ?  That  this  is  so  is  recognized  in 


OF  THE   IMMEDIATE   FUTURE  135 

the  steps  towards  the  desired  end  taken  in  recent  years 
by  the  Local  Government  Board  jointly  with  local  au- 
thorities. Let  me  enumerate  some  of  these.  The 
Central  Authority  have  undertaken  to  pay  one-half  of 
approved  expenditure  incurred  locally  on  the  follow- 
ing agencies: 

(a)  The  salaries  and  expenses  of  inspectors  of  mid- 
wives  ; 

(&)  The  salaries  and  expenses  of  health  visitors  and 
nurses  engaged  in  maternity  and  child  welfare  work; 

(c)  The  provision  of  a  midwife  for  necessitous 
women  in  confinement  and  for  areas  which  are  insuffi- 
ciently supplied  with  this  service; 

(d)  The  provision,  for  necessitous  women,  of  a 
doctor  for  illness  connected  with  pregnancy  and  for 
aid  during  the  period  of  confinement  for  mother  and 
child  ; 

(0)  The  expenses  of  a  Centre,  i.e.,  an  institution 
providing  any  or  all  of  the  following  activities :  Med- 
ical supervision  and  service  for  expectant  and  nursing 
mothers,  and  for  children  under  five  years  of  age,  and 
medical  treatment  at  the  Centre  for  cases  needing  it ; 

(/)  Arrangements  for  instruction  in  the  general  hy- 
giene of  maternity  and  childhood ; 

(g)  Hospital  treatment  provided  or  contracted  for 
by  local  authorities  for  complicated  cases  of  confine- 
ment or  complications  arising  after  parturition,  or  for 
cases  in  which  a  woman  to  be  confined  suffers  from 


136        SOME   PROBLEMS  OF  PREVENTIVE   MEDICINE 

illness  or  deformity,  or  for  cases  of  women  who,  in 
the  opinion  of  the  Medical  Officer  of  Health  cannot 
with  safety  be  confined  in  their  homes  or  such  other 
provision  for  securing  proper  conditions  for  the  con- 
finement of  necessitous  women  as  may  be  approved 
by  the  Medical  Officer  of  Health ; 

(/*)  Hospital  treatment  provided  or  contracted  for 
by  local  authorities  for  children  under  five  years  of 
age  found  to  need  in-patient  treatment ; 

(»)  The  cost  of  food  provided  for  expectant  mothers 
and  nursing  mothers  and  for  children  under  five  years 
of  age,  where  such  provision  is  certified  by  the  Medical 
Officer  of  the  Centre  or  by  the  Medical  Officer  of 
Health  to  be  necessary  and  where  the  case  is  neces- 
sitous ; 

(/)  Expenses  of  creches  and  day  nurseries  and  of 
other  arrangements  for  attending  to  the  health  of  chil- 
dren under  five  years  of  age,  whose  mothers  go  out 
to  work ; 

(&)  The  provision  of  accommodation  in  convales- 
cent homes  for  nursing  mothers  and  for  children  under 
five  years  of  age ; 

(/)  The  provision  of  homes  and  other  arrangements 
for  attending  to  the  health  of  children  of  widowed, 
deserted  and  unmarried  mothers,  under  five  years  of 
age; 

(m)  Experimental  work  for  the  health  of  expectant 
and  nursing  mothers  and  of  infants  and  children  under 


OF  THE   IMMEDIATE   FUTURE  137 

five  years  of  age,  carried  out  by  local  authorities  or 
voluntary  agencies  with  the  approval  of  the  Board ; 

(«)  Contributions  by  the  local  authority  to  volun- 
tary institutions  and  agencies  approved  under  the 
scheme. 

Grants  will  be  paid  to  voluntary  agencies  aided  by 
the  Board  on  condition: 

1.  That  the  work  of  the  agency  is  approved  by  the 
Board  and  coordinated  as  far  as  practicable  with  the 
public  health  work  of  the  local  authority  and  the  school 
medical  service  of  the  local  education  authority. 

2.  That  the  premises  and  work  of  the  institution  are 
subject  to  inspection  by  any  of  the  Board  officer's  or 
inspectors. 

3.  That  records  of  the  work  done  by  the  agency  are 
kept  to  the  satisfaction  of  the  Board. 

Possibly  much  of  the  past  failure  to  protect  mater- 
nity and  to  reduce  the  still-births  and  mortality  among 
infants  under  a  month  old  has  been  due  to  the  erro- 
neous assumption  that  damage  to  health  and  life  at 
these  times  is  in  the  main  inevitable.  That  this  is  not 
so  for  maternal  mortality  is  proved  by  the  great  dif- 
ference in  experience  of  sickness  and  death  for  mothers 
in  different  social  strata  and  according  to  the  availa- 
bility of  skilled  midwives  and  doctors.  There  are 
similar  differences  locally  and  socially  in  the  propor- 
tion of  still-births.  Wassermann  tests,  followed  by 
appropriate  medical  action,  in  all  instances  in  which 


138       SOME   PROBLEMS  OF  PREVENTIVE   MEDICINE 

there  have  been  previous  miscarriages  or  in  which  for 
other  reasons  syphilis  comes  under  suspicion,  and  sub- 
sequent action  based  on  the  diagnosis  thus  secured, 
would  at  once  greatly  reduce  maternal  and  infantile 
mortality.  So  also  would  systematic  examination  of 
urine  during  pregnancy  and  the  ascertainment  that  in 
other  respects  the  physical  conditions  of  normal  par- 
turition are  present.  These  are  adequate  reasons  for 
the  establishment  of  ante-natal  consultations,  which 
happily  are  rapidly  increasing  in  England  under  the 
stimulus  of  the  Government  grants  already  mentioned. 

The  further  fact  that  about  one-third  of  the  total 
deaths  in  the  first  year  after  live-birth  occur  in  the 
first  four  weeks  of  life,  adds  force  to  my  plea  for  the 
establishment  of  these  ante-natal  consultations  in  con- 
nection with  all  lying-in  institutions  and  at  child  wel- 
fare centres,  where  infants  and  children  up  to  school 
age  will  be  submitted  to  periodical  medical  examina- 
tion and  supervision. 

It  has  been  erroneously  asserted  that  the  greater 
part  of  this  early  infant  mortality  is  unavoidable ;  but 
careful  examination  of  national  and  local  statistics 
shows  that  in  some  places  it  is  twice  as  high  as  in  others, 
and  examination  of  the  causes  of  death  in  the  districts 
with  more  favourable  mortality  shows  that  their  ex- 
perience can  be  improved.  All  experienced  obstetri- 
cians and  paediatricians  will  agree  that,  given  adequate 
care  of  the  mother  during  pregnancy,  skilled  care  by 


OF  THE  IMMEDIATE   FUTURE  139 

a  competent  obstetrician  during  labor,  and  satisfactory 
medical  and  nursing  care  in  the  following  month,  there 
can  be  secured  large  reductions  in  the  early  infant 
mortality  of  the  first  month  after  birth,  as  well  as  in 
the  number  of  still-births  and  in  the  present  toll  on 
maternal  life. 

In  early  infancy,  as  in  advanced  old  age,  the  hold  on 
life  is  slight,  normal  and  abnormal  are  soon  inter- 
changed, and  there  is  needed  not  only  more  knowledge 
on  the  part  of  mothers  and  nurses,  and  even  of  physi- 
cians, of  the  hygienic  side  of  medicine  as  applied  to 
the  physiological  life  of  the  mother  and  her  infant, 
but  also  personal  care  and  assistance  to  enable  the 
mother  to  apply  the  useful  information  and  advice 
given  by  the  public  health  nurse.  I  lay  special  stress 
on  this  association  of  counsel  and  assistance.  It  is^ 
important  also  that  nursing  and  medical  assistance 
should  be  so  given  as  not  to  create  a  feeling  of  de- 
pendence. In  view  of  the  wide  provision  of  medical 
assistance  from  public  funds  which  already  obtains, 
I  submit  that  poverty  tests  in  the  giving  of  such  as- 
sistance should  be  abolished,  or  that,  at  least,  the 
availability  of  such  assistance  should  be  greatly  ex- 
tended. Given  the  fulfilment  of  this  condition,  it  will 
be  practicable  to  enlist  the  remunerated  cooperation 
of  the  medical  profession  in  a  general  provision  of 
medical  and  nursing  facilities,  which  will  secure  the 
early  detection  of  disease  of  every  kind  and  its  prompt 


I4O       SOME   PROBLEMS   OF  PREVENTIVE   MEDICINE 

and  adequate  treatment.  Not  only  so,  but  the  same 
service  can  be  utilized  for  the  preservation  of  health 
by  securing  the  change  of  habits  and  customs  and  con- 
ditions of  housing  or  work  which  are  likely  to  prove 
detrimental. 

I  have  laid  stress  on  the  ideal  after  which  we  must, 
in  my  opinion,  strive.  Meanwhile,  it  is  essential  that 
we  should  not  regard  the  mere  removal  of  ignorance 
as  the  summum  bonum.  This  is  plain  when  we  come 
into  close  contact  with  the  facts  of  life  as  lived  by  the 
greater  part  of  the  wage-earning  classes. 

Has  the  wife  of  the  wage-earner  domestic  help  such 
as  her  well-to-do  sister  possesses?  Is  there  a  nurse 
to  help  her  even  when  the  children  are  sick,  much  less 
while  they  remain  fairly  healthy?  How  often  has 
every  kettle-full  of  water  to  be  heated  separately  on  a 
stove?  Under  such  circumstances  is  it  reasonable  to 
expect  the  cleanliness  which  is  an  indispensable  con- 
dition of  health?  Is  there  a  clean  supply  of  milk  for 
every  working-man's  family  and  are  there  arrange- 
ments for  sanitary  and  cool  storage  of  food  in  his 
dwelling  ? 

And  so  we  might  go  on  multiplying  questions,  know- 
ing that,  if  the  answers  are  well-informed  and  candid, 
they  will  confess  that  the  mothers  of  the  wage-earning 
classes,  especially  in  our  large  cities — in  England,  if 
not  also  here — have  not  a  fair  chance  to  keep  them- 
selves well,  or  to  rear  a  healthy  and  robust  family. 


OF   THE   IMMEDIATE   FUTURE  14! 

I  do  not  wish  to  stress  this  view  of  the  case ;  but  I 
have  said  enough  to  justify  the  action  of  the  British 
Government  in  deciding  during  the  war — and  an- 
nouncing the  fact  in  more  than  one  official  circular 
issued  to  all  Local  Authorities  by  the  Local  Govern- 
ment Board — that,  next  to  the  active  pursuance  of 
war,  measures  for  promoting  maternal  and  child  wel- 
'  fare  ranked  next  in  importance,  and  that  no  efforts 
must  be  spared  to  continue  and  extend  such  measures. 
And  the  history  of  the  last  four  years  shows  that  this 
has  been  done.  The  central  grants  for  special  mater- 
nal and  child  welfare  work  undertaken  by  local  au- 
thorities and  voluntary  agencies  have  increased  twelve- 
fold, the  number  of  health  visitors  has  been  more  than 
doubled,  and  the  number  of  maternity  and  child  wel- 
fare centres  has  increased  five-fold;  and  coincident 
with  these  facts,  infant  mortality,  which  was  falling 
before  the  war,  has  continued  to  decline  steadily  dur- 
ing the  war, — the  corrected  figures  for  the  years  1912- 
17  respectively  were  104,  117,  113,  in,  98,  and  94 — 
although  the  number  of  mothers  employed  away  from 
home  has  greatly  increased  during  the  same  period. 

The  Work  of  Voluntary  Agencies 
I  have  several  times  in  this  address  mentioned  the 
valuable  work  of  voluntary  health  agencies.     No  offi- 
cial can  fail  to  recognize  that  pioneer  work  is  com- 
monly started  by  them ;  and  it  has  often  happened  that 


142       SOME   PROBLEMS  OF  PREVENTIVE   MEDICINE 

only  when  the  evidence  of  its  value  has  become  ob- 
trusive has  it  been  taken  over  by  local  authorities. 
This  is  the  true  function  of  voluntary  agencies,  and 
will  remain  so,  until  local  authorities  (which  after  all 
are  manned  by  voluntary  workers)  become  saturated 
with  the  ideals  of  voluntary  workers  and  of  the  new 
women-voters.  Local  authorities  always  have  one 
great  advantage  over  voluntary  societies,  that  their 
action  can  be  supported  by  legal  powers. 

The  proper  attitude  of  voluntary  workers  is  to  ini- 
tiate and  demonstrate  the  value  of  reforms,  to  per- 
suade local  authorities  to  adopt  them,  themselves  to 
become  members  of  these  local  authorities  to  ensure 
this  end,  and  thus  eventually  render  the  voluntary 
organization  for  the  object  in  question  superfluous. 
There  need  be  no  fear ;  openings  for  further  desirable 
voluntary  work  will  always  appear,  as  official  work 
increases.  In  the  main,  however,  the  care  of  the  health 
of  the  people  is  a  governmental  function,  whether  it 
has  to  do  with  the  prevention  of  sickness  or  the  satis- 
factory medical  treatment  and  nursing  of  the  sick. 

There  is  no  early  prospect  of  voluntary  workers  be- 
coming unnecessary;  for  average  human  nature,  as 
represented  on  governmental  bodies,  is  shortsighted 
and  needs  much  education,  morally  and  intellectually, 
before  it  will  undertake  the  whole  sphere  of  work 
called  for  in  the  interest  of  the  welfare  of  the  mother 
and  her  child.  Hence  my  plea  that  the  magnificent 


OF  THE  IMMEDIATE   FUTURE  143 

potentialities  of  the  Red  Cross  organization  should  not 
be  allowed  to  fall  into  abeyance ;  that  they  should  re- 
place their  relief  work  by  preventive  work;  that,  to 
use  a  well-known  simile,  they  should  erect  a  parapet 
at  the  top  of  a  dangerous  cliff  as  well  as  provide  am- 
bulances at  its  foot.  In  so  doing  they  will,  I  am  con- 
fident, not  encroach  on  present  successful  work  of 
existing  bodies  concerned  with  promoting  child  wel- 
fare, or  with  the  prevention  of  tuberculosis  or  of 
venereal  diseases,  or  with  existing  agencies  for  pro- 
viding nurses  for  the  poor.  But  they  can  supplement 
the  efforts  of  these  organizations;  they  can  bring 
monetary  as  well  as  personal  assistance ;  and  they  can, 
above  all,  bring  a  mass  of  public  opinion  to  bear  on 
local  and  central  governing  bodies  which  will  lead  to 
the  only  real  economy,  which  consists  in  expenditure 
on  an  adequate  scale,  bringing  to  the  aid  of  the  fami- 
lies of  the  people  the  preventive,  the  medical,  and  the 
nursing  facilities  of  which  they  remain  in  need. 


CHAPTER    VI 

THE  INTER-RELATION  OF  VARIOUS  SOCIAL  EFFORTS* 

On  examining  the  local  city  directory,  one  cannot 
but  be  impressed  by  the  multiplicity  of  voluntary  or- 
ganizations having  for  their  object  the  immediate  re- 
lief of  destitution  or  the  social  or  economic  "  uplift " 
of  sections  of  the  population.  The  multiplicity  of 
these  agencies  becomes  more  striking  when  one  re- 
members that  probably  every  one  of  the  hundreds  of 
churches  and  chapels  in  the  city  has  its  periodical  sac- 
ramental and  other  collections  for  the  poor,  and  may 
have  also  a  system  of  parochial  district  visiting,  with 
such  auxiliary  assistance  as  is  provided  through 
mothers'  meetings,  etc.  Nor  does  this  exhaust  the 
possibilities  of  social  help  available  for  the  poorer 
members  of  society  in  cities  in  which  there  is  a  satis- 
factory distribution  of  rich  and  poor,  that  is,  in  which 
the  segregation  of  different  social  strata  in  separate 
areas  has  happily  not  befallen.  There  is  the  further 
help  provided  by  individual  charity,  the  amount  of 
which  in  the  aggregate  probably  exceeds  beneficence 
through  churches  and  social  agencies. 

1  An  address  to  the  Alpha-Kappa-Kappa  Club,  Johns  Hop- 
kins University,  Wednesday,  December  10,  1919. 

144 


INTER-RELATION   OF  VARIOUS   SOCIAL   EFFORTS    145 

If  these  different  agencies  could  pool  their  resources, 
while  retaining  the  enthusiasm  and  driving  power  of 
separate  organization,  what  an  economy  of  effort  and 
what  increase  of  efficiency  would  result,  especially  if 
these  agencies  were  also  satisfactorily  related  to  the 
official  organizations  of  local  and  central  governing 
bodies  having  the  same  object ! 

But  I  am  not  concerned  this  evening  to  discuss  the 
machinery  of  social  help  or  the  attempts  already  made 
in  different  centres  for  securing  their  satisfactory  co- 
operation. Nor  am  I  disposed  to  discuss  the  economic 
problems  underlying  the  need  for  social  assistance  of 
the  poor.  Ideally  we  must  agree  with  St.  Augustine's 
statement:  "Thou  givest  bread  to  the  hungry;  but 
better  were  it,  that  none  hungered,  and  that  thou 
had'st  none  to  give  him."  My  present  object,  however, 
is  to  set  out  some  elementary — and  when  stated  fairly 
obvious — considerations  bearing  on  social  evils  and 
their  remedies  under  present  conditions  of  society, 
the  recollection  of  which  if  followed  by  practical  ac- 
tion, would  secure  greatly  increased  efficiency  in  social 
work. 

For  the  following  reasons  I  do  not  hesitate  to  bring 
this  subject  before  a  gathering  of  graduate  medical 
students : 

First. — Every  physician  as  soon  as  he  engages  in 
medical  practice  almost  immediately  comes  into  touch 
with  organized  and  unorganized  social  workers,  and 
ii 


146    INTER-RELATION   OF  VARIOUS   SOCIAL  EFFORTS 

his  success — personal  as  well  as  communal — can  al- 
most be  measured  in  terms  of  his  outlook  towards  their 
work ; 

Second. — The  physician,  with  his  scientific  training 
in  the  tracing  of  effects  back  to  their  causes,  is  in  a 
specially  favourable  position  to  promote  rational  as 
contradistinguished  from  empirical  social  help ;  and 

Third. — The  physician  is  now  learning  to  appreciate 
that  he  can  only  treat  his  patients  satisfactorily  in  the 
light  of  knowledge  of  their  social,  including  housing 
conditions,  of  their  industrial  relationships,  and  of 
their  personal  history  and  habits  of  life. 

This  is  the  age  of  anxiety  to  give  social  help. 

I  hold  strongly  the  view  that  ere  many  of  you  are 
advanced  in  years  the  fundamentally  important  social 
help  which  is  constituted  by  adequate  medical  attend- 
ance will  be  provided,  for  all  who  wish  to  have  it  thus, 
at  the  expense  of  the  state,  i.e.,  cooperatively  by  means 
of  common  charges  on  every  member  of  the  com- 
munity according  to  his  means,  exactly  as  elementary 
education  is  now  provided.  This  will  involve  radical 
reconstruction  of  the  relationship  between  hospital  and 
private  medical  practice,  and  will,  I  trust,  include  also 
the  introduction  of  preventive  medicine  into  the  prac- 
tice of  every  physician.  But  this  is  in  the  future. 
How  can  medical  practice  under  present  conditions, 
and  how  can  non-medical  social  agencies,  be  made  sub- 
servient to  the  fullest  extent  to  the  welfare  of  the  com- 
munity ? 


INTER-RELATION   OF  VARIOUS   SOCIAL   EFFORTS     147 

A  few  elementary  illustrations  will  show  the  many 
tmexploited  or  only  partially  exploited  or  misused 
opportunities  for  efficient  social  help. 

The  greatest  science  is  to  know  the  causes  of  things ; 
and  there  is  no  branch  of  work  in  which  this  is  more 
important  than  in  medicine.  But  causation  is  com- 
plex. A  given  result  commonly  follows  from  a  chain, 
or  it  may  be  a  bundle  of  events:  and  as  we  shall 
shortly  see  the  end  links  of  the  chain  are  oftimes 
joined,  thus  forming  a  circle. 

If  a  man  shoots  a  companion  with  whom  he  has 
quarrelled,  it  may  be  urged  that  a  more  rigid  system 
of  license  for  the  use  of  firearms  would  have  prevented 
the  calamity;  that  the  companion  was  also  quarrel- 
some ;  that  the  homicide  had  been  the  spoiled  child  of 
his  mother  and  had  not  had  a  satisfactory  up-bringing ; 
and  that  he  inherited  from  his  father  a  violent  temper ; 
but  none  of  these  circumstances, — all  of  which  may 
have  contributed  to  the  murder, — is  likely  to  succeed 
in  preventing  the  murderer  from  being  hanged  after 
due  trial. 

It  would  be  difficult  to  find  a  more  striking  instance 
of  the  linking  of  elements  in  causation  than  in  the 
origin  of  a  case  of  malaria.  For  the  transmission  of 
this  disease  two  human  beings,  one  already  infected 
with  the  specific  contagium,  and  a  mosquito  are  re- 
quired, and  the  chain  of  causation  can  be  broken  at 
the  infecting  person,  by  strict  screening  from  mos- 


148    INTER-RELATION   OF  VARIOUS   SOCIAL   EFFORTS 

quitos,  and  by  the  use  of  quinine ;  at  the  mosquito  by 
preventing  its  emergence  from  the  larval  stage,  and 
later  by  preventing  its  access  to  the  patient ;  or  at  the 
prospective  patient,  possibly  by  prophylactic  medica- 
tion, more  certainly  by  strict  screening  from  mos- 
quitos.  Hence  one  might  claim  lack  of  segregation 
of  infected  persons,  lack  of  screening  of  the  healthy, 
failure  to  drain  marshes,  to  apply  oil  to  the  surface 
of  stagnant  pools;  or  to  adopt  allied  measures  destroy- 
ing the  larvae  of  mosquitos  as  each  of  them  the  cause 
of  malarial  disease. 

There  is  a  constant  excess  of  sickness  among  the 
poor  as  compared  with  the  well-to-do.  Measures  for 
the  relief  of  poverty,  therefore,  may  be  regarded  as 
within  the  scope  of  the  physician's  prescription.  This 
may  be  accomplished  for  the  moment  by  monetary  or 
material  help;  but  unless  the  causes  of  poverty  are 
sought  out  and  counteracted,  the  assistance  given  is 
merely  palliative.  For  nothing  is  more  certain  than 
that  poverty  tends  to  become  a  self -perpetuating  con- 
dition. 

Thus  poverty  leads  to  premature  employment  of 
children,  with  detriment  to  their  normal  growth,  fol- 
lowed by  diminished  efficiency  in  adult  life.  This  im- 
plies low  wages  throughout  life,  and  so  poverty  is 
passed  on  to  a  second  generation. 

Evidently  timely  assistance  to  induce  the  parent  to 
delay  employing  the  boy,  until  he  has  been  prepared 


INTER-RELATION  OF  VARIOUS   SOCIAL  EFFORTS    149 

for  work,  and  to  ensure  his  being  put  to  work  which 
will  not  be  a  "  blind-alley  "  occupation,  might  have  ob- 
viated the  evil  chain  of  events. 

Poverty  again  when  carried  to  the  point  of  destitu- 
tion may  tempt  to  larceny;  this  may  be  followed  by 
loss  of  employment,  and  so  the  temporary  unrelieved 
poverty  is  liable  to  become  permanent. 

Intemperance  has  been  almost  wiped  out  as  a  cause 
of  disease  in  the  United  States;  and  we  have  in  the 
fact  that  the  whole  country  has  "  gone  dry  "  a  remark- 
able example  of  a  "  short-cut "  towards  social  salvation 
from  alcoholism  which  will  be  most  instructive.  Apart 
from  such  universal  prohibition  of  alcoholic  bever- 
ages, the  physician  has  to  think  of  an  alcoholic  patient 
under  his  care  as  the  possible  victim  of  one  or  more  or 
all  of  several  cooperating  influences  conducing  to  in- 
temperance. The  alcoholic  habit  may  have  been  grad- 
ually acquired  as  the  result  of  protracted  social  indul- 
gence in  moderation  acting  on  a  person  of  unstable 
mental  constitution ;  it  may,  especially  in  wage-earners, 
have  been  hastened  by  the  evil  custom  of  treating.  It 
not  infrequently  follows  overwork,  with  the  associated 
feeling  of  need  for  stimulants;  it  accompanies  bad 
housing,  with  unsatisfactory  sleeping  accommodation; 
and  it  is  aided  by  poor  and  badly  cooked  food,  due  to 
shiftlessness,  overwork,  or  lack  of  domestic  training 
of  the  man's  wife.  If  there  is  to  be  successful  control 
of  alcoholism,  action  in  all  the  directions  briefly  indi- 


150    INTER-RELATION   OF  VARIOUS   SOCIAL  EFFORTS 

cated  above,  and  in  other  directions  which  will  suggest 
themselves,  is  necessary;  and  although  the  physician 
cannot  himself  do  all  this,  his  efforts  should  run  par- 
allel with  social  efforts  in  these  directions. 

Even  when  the  "short-cut"  of  compulsory  absti- 
nence has  been  taken,  the  efforts  indicated  above  are 
still  needed ;  for  alcoholism  is  not  the  only  resultant  of 
bad  social  habits,  of  overwork,  of  unsatisfactory  feed- 
ing, of  deficient  sleep,  and  so  on. 

Perhaps  even  more  far  reaching  in  their  evil  effects 
than  intemperance  are  the  Venereal  Diseases.  As  you 
know,  special  efforts  during  and  since  the  war  have 
been  made  to  limit  the  spread  of  these  diseases.  I  do 
not  propose  to  trouble  you  with  statistics  to  prove  the 
mischief  caused  by  these  diseases.  Has  not  Osier  said 
that  the  whole  of  clinical  medicine  can  be  taught 
around  syphilis,  and  that  it  is  the  third  in  importance 
of  the  killing  diseases?  And  as  a  further  illustration, 
let  me  add  that  no  less  than  one-tenth  of  the  total 
accommodation  in  our  lunatic  asylums  might  be  dis- 
pensed with  if  syphilis  were  eliminated. 

Among  the  measures  being  taken  to  combat  these 
diseases  are  educational  propaganda,  and  the  provision 
of  clinics,  free  for  all,  at  which  patients  may  be  treated 
promptly  and  adequately.  It  is  evident,  however,  that 
if  the  medical  and  educational  efforts  now  being  made 
are  to  succeed  they  must  include  recognition  of  all  the 
factors  causing  sexual  vice,  and  appropriate  action  in 


INTER-RELATION   OF  VARIOUS   SOCIAL   EFFORTS    151 

respect  of  each  of  these — they  must  indeed  go  further 
than  this;  for  self-restraint  is  a  wider  problem  than 
in  relation  to  exposure  to  these  diseases.  It  embraces 
the  whole  subject  of  formation  of  the  habit  of  self- 
control.  One  of  the  most  striking  facts  in  the  great 
war  has  been  the  extent  to  which  young  girls  of  pre- 
viously decent  behaviour  have  fallen  victims  to  what 
has  sometimes  appeared  to  be  passion  combined  with 
a  perverted  form  of  patriotism ;  and  one  of  the  meas- 
ures most  called  for  is  better  mothering  and  maternal 
training  of  both  girls  and  boys.  The  problem  is  one 
of  special  difficulty  as  regards  the  economically  inde- 
pendent girl ;  and  to  shield  her  the  combined  efforts  of 
home  influence,  of  girls'  clubs,  and  of  various  social 
and  religious  organizations  are  all  required. 

Judicious  and  restrained  teaching  of  the  physiology 
and  hygiene  of  sex  would  do  much  to  counteract  the 
evil  influence  of  bad  teaching  by  companions ;  and  in 
emphasizing  this  duty  on  parents  the  physician  may  do 
untold  good.  So  also,  especially  when  the  daughters 
of  his  patients  are  about  to  marry  "men  of  the  world," 
he  should  urge  the  need  for  asking  a  satisfactory  cer- 
tificate from  the  intended  bridegroom  of  freedom 
from  infection. 

The  influence  of  unaccustomed  alcoholic  indulgence 
in  leading  to  the  first  "  slip,"  often  with  the  production 
of  life-long  disease,  is  well  known. 

Nor  must  we  leave  out  of  account  the  tolerance  of 


152    INTER-RELATION   OF  VARIOUS    SOCIAL   EFFORTS 

vice  in  conversation  between  young  men,  as  a  frequent 
excuse  of  and  even  excitant  to  vice.  The  happiest 
young  man  is  he  who  can  go  to  the  marriage  ceremony 
with  the  same  sexual  purity  as  is  even  now  expected 
from  the  bride.  Is  it  too  much  to  expect  that  our 
social  conscience  will  grow  up  to  this  standard?  I 
think  not;  and  when  this  point  has  been  reached, 
venereal  diseases  will  have  almost  entirely  disap- 
peared, and  the  sum  total  of  human  happiness  and 
efficiency  will  be  enormously  enhanced. 

Meanwhile  partial  remedies  must  be  pushed  for  all 
they  are  worth — and  this  is  much.  Fear  of  conse- 
quences may  deter  some  from  vice;  fear  of  conse- 
quences to  future  wife  and  child  form  a  much  more 
potent  argument.  Treatment  of  venereal  diseases,  es- 
pecially of  syphilis,  is  a  most  valuable  means  of  pre- 
venting their  spread.  This  treatment  may  be  urged 
even  at  the  stage  after  exposure  to  infection  before 
any  symptoms  of  illness  appear;  and  the  more 
promptly  this  is  done  the  more  successful  is  it.  There 
has  been  much  heated  debate  as  to  whether  persons 
known  to  intend  to  expose  themselves  to  possible  in- 
fection should  be  provided  with  disinfectant  or  other 
arrangements  for  obviating  infection.  This  cannot  be 
done  without  some  loss  of  moral  position;  it  almost 
makes  the  provider  a  co-partner  with  the  sensualist. 
It  may  be  urged,  however,  but  with  dubious  cogency, 


INTER-RELATION   OF  VARIOUS   SOCIAL   EFFORTS    153 

that  if  the  man  is  told  beforehand  that  immediately 
afterwards  he  can  have  access  to  disinfectant  pro- 
visions, the  same  objection  holds  good.  I  do  not 
regard  the  provision  of  "outfits"  as  wise.  Evidence 
tends  to  the  conclusion  that  they  are  commonly  not 
used  efficiently;  and  there  is  a  distinct  loss  in  the 
moral  position  by  their  use.  The  whole  subject  is  one 
of  great  difficulty.  The  prevention  of  venereal  dis- 
eases is  clearly,  however,  not  merely  a  medical  prob- 
lem; and  the  physician  who  realises  this  and  throws 
the  weight  of  his  influence,  in  warning  and  in  counsel, 
on  the  side  of  moral  restraint,  is  adding  greatly  to  the 
value  of  his  social  service  to  the  community. 

Other  instances  will  occur  to  you,  illustrating  the 
importance  of  a  broad  outlook  in  the  causation  of  dis- 
ease or  other  forms  of  social  misery.  I  will  adduce 
one  more.  It  is  well  known  that  infant  mortality  is 
much  heavier  among  the  poor  than  among  the  well- 
to-do.  The  rule  does  not  hold  universally  in  rural 
areas,  but  in  towns  it  applies  almost  without  excep- 
tion. And  it  is  assumed  by  a  large  school  of  social 
workers  that  enlightenment  of  the  ignorance  of  the 
poor  mother  will  effectively  correct  this  evil.  Such  a 
lop-sided  view  ignores  many  of  the  elements  of  the 
problem  of  infant  mortality.  Think  for  a  moment  of 
the  contrast  between  the  working-class  mother  of  five 
children  living  in  a  small  city  tenement,  and  the 
mother  of  an  equal  number  of  children  in  easy  circum- 

\ 


154    INTER-RELATION   OF  VARIOUS   SOCIAL   EFFORTS 

stances,  living  in  a  residential  suburb,  and  having 
domestic  servants,  a  nurse,  and  a  physician  always 
available.  The  two  mothers  probably  differ  but  little 
in  their  knowledge  of  the  hygiene  of  infancy ;  but  the 
one  has  helpers  to  ensure  scrupulous  cleanliness,  to 
prevent  over-fatigue  of  the  nursing  mother,  to  de- 
tect the  first  sign  of  infantile  illness  and  provide  the 
needed  action ;  while  the  other  mother  has  to  struggle 
alone  in  respect  of  her  infant,  without  either  domestic 
or  nursing  assistance,  the  struggle  being  complicated 
by  the  fact  that  the  care  of  four  older  children  and  of 
her  husband  is  on  her  shoulders.  Even  when  there 
is  no  actual  direct  poverty  in  the  working-class  home, 
the  differences  thus  indicated — supplemented  by  the 
inability  of  the  mother  to  obtain  medical  advice  for 
apparently  minor  ailments — outweigh  enormously  the 
factor  of  ignorance  as  a  cause  of  excessive  infant 
mortality.  By  all  means  let  instruction  be  given  by 
public  health  nurses  or  other  agencies,  and  this  is  most 
valuable;  but  it  does  not  fully  meet  the  needs  of  the 
X  case.  There  is  required  also  actual  domestic,  as  well 
as  nursing,  assistance  in  the  home  of  the  overworked 
working-class  mother,  especially  after  the  birth  of  her 
infant  and  when  illness  attacks  any  of  her  children; 
and  unless  the  physician  realises  these  elements  in  the 
problem,  his  efforts  in  securing  the  welfare  of  his  pa- 
tient and  in  reducing  infant  mortality  can  have  but 
partial  success. 


INTER-RELATION   OF  VARIOUS   SOCIAL  EFFORTS    155 

The  main  lessons  arising  from  the  foregoing  illus- 
trations of  medical  and  social  problems  are  two :  Each 
evil  should  be  attacked  in  its  causal  relationships ;  and 
causation  is  multiple. 

Hence — apart  from  total  prohibition — in  attacking 
alcoholism,  the  physician  may  bless  the  efforts  of  tee- 
total advocates,  of  those  engaged  in  reducing  the  num- 
ber of  saloons,  of  those  securing  better  dietetics  and 
cooking,  less  industrial  fatigue,  or  more  satisfactory 
domestic  sleeping  accommodation,  and  of  parents  and 
teachers  engaged  in  promoting  self-control  in  the 
young  as  a  habit  of  life;  and  he  will  call  them  all  in 
aid  of  his  curative  and  preventive  life  work. 

So,  also  in  the  control  of  venereal  diseases,  early 
and  prompt  diagnosis  and  treatment  must  go  hand  in 
hand  with  police  measures  for  the  suppression  of  pros- 
titution, with  educational  work  respecting  these  dis- 
eases, and  with  the  inculcation  of  a  higher  standard 
of  morality,  considered  as  part  of  the  general  cultiva- 
tion of  moral  self-restraint. 

And  in  the  prevention  of  infant  mortality  and  of  the 
even  more  serious  handicapping  of  the  up-growing 
child  produced  by  the  factors  of  infant  mortality,  we 
need  to  bring  to  bear  all  our  medical  and  hygienic 
knowledge,  and  to  realise  that  until  every  mother  in 
the  land  is  furnished  with  the  elementary  require- 
ments, domestic,  sanitary,  social,  and  medical,  for  rear- 
ing a  healthy  family,  we  have  no  right  to  mental  com- 


156    INTER-RELATION    OF  VARIOUS   SOCIAL   EFFORTS 

fort  while  enjoying  these  elementary  needs  of  family 
life  ourselves. 

Cooperation  and  solidarity  of  effort  are  needed  on 
the  part  of  the  multitude  of  workers  engaged  in  social 
work  for  the  community — official  and  non-official ;  and 
in  bringing  this  about  the  physician  of  the  early  future 
will,  I  am  confident,  take  a  leading  part. 


CHAPTER  VII 

THE  OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS1 

There  are  two  ways  in  which  Health  Problems  can 
be  approached :  what  may  be  called  the  microscopic 
method,  which  examines  in  minute  detail  each  indi- 
vidual problem ;  and  the  conspective  method,  in  which 
an  attempt  is  made  to  obtain  an  unbiased  and  com- 
parative view  of  the  chief  problems  concerned,  in 
order  that  their  relative  importance  may  be  assessed, 
and  the  possibilities  of  improvement  may  be  gauged. 
In  proposing  to  myself  the  latter  and  more  difficult 
task,  I  appreciate  the  impossibility  of  discussing  all 
the  items  which  emerge. 

I  would  not  have  us  forget  what  has  already  been 
achieved.  Taking  the  national  figures  for  England 
and  Wales  as  an  illustration,  it  is  noteworthy  that  the 
death-rate  from  all  causes  fell  from  22.4  per  1,000  of 
population  in  1846-50  to  13.8  in  1911-15,  a  reduction 
of  nearly  40  per  cent.  Comparing  the  decennium 
1871-80  with  the  quinquennium  1911-15,  the  inci- 
dence of  reduction  of  death-rate  at  different  ages  was 
as  follows: 

1  A  lecture  given  to  the  Alumni  Association  of  the  Univer- 
sity of  Yale,  January  22,  1920. 

157 


158      OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 
Percentage  reduction  in  death-rate 

Age  Age 

0-5  •  • 42         35-45  42 

5-io  48         45-55  25 

10-15  43         55-65  IS 

15-20  46         65-75  10 

20-25  51          75-85  7 

25-35  50         85  and  upwards 15 

The  survey  is  saddened  by  the  terrible  losses  of  War, 
and  the  even  more  devastating  ravages  of  influenza; 
and  we  realize  our  inadequacy  to  prevent  catarrhal 
infections,  until  further  research  into  preventive  possi-, 
bjlities  proves  successful,  and  until  the  standard  of 
universal  conduct  for  catarrhal  affections  becomes 
much  higher  than  at  present.  We  realize  furthermore 
that  probably  at  least  half  the  deaths  from  all  causes 
which  occur  could  be  postponed  until  old  age.  But  the 
standard  of  health  of  the  general  population  has  greatly 
improved;  typhus  has  practically  disappeared  under 
peace  conditions;  yellow  fever  approaches  its  demise; 
malaria  and  typhoid  are  controllable ;  tuberculosis  and 
venereal  diseases  are  only  waiting  for  systematic,  com- 
plete, and  continuous  measures  to  secure  their  rapid 
decline  or  actual  disappearance;  the  mortality  from 
childbearing  and  of  young  children  has  greatly  de- 
clined; and  this  is  an  incomplete  statement  of  what 
has  already  been  done. 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS      159 

Obstacles 

This  improvement  is  all  the  more  remarkable  in 
view  of  the  additional  obstacles  imposed  to  health  im- 
provement by  modern  conditions  of  urban  and  indus- 
trial life. 

Urbanisation 

The  population  during  the  last  century  has  steadily 
flocked  to  the  towns  from  country  districts.  Streets 
have  taken  the  place  of  green  fields ;  rows  of  unsatis- 
tory  dwellings  have  replaced  country  cottages;  we 
have  dust  and  belching  smoke  and  noise  instead  of 
sunshine  and  country  air  and  quiet ;  bustle  and  turmoil 
instead  of  life  in  close  touch  with  mother-earth:  and 
this  change  has  been  associated  with  an  almost  unlim- 
ited inter-communication  of  human  beings,  and  a  cor- 
responding increase  in  opportunities  for  the  convec- 
tion of  germs  of  disease. 

Until  the  time  of  the  industrial  revolution  in  Eng- 
land modes  of  locomotion  were  little  if  any  more  ad- 
vanced than  among  the  ancient  Egyptians ;  and  4is_ease, 
when  it  travelled  at  all,  travelled  by  slow  and  delib- 
erate stages.  Now  the  infections  of  the  entire  world 
may  be  sampled  in  any  one  district  in  the  course  of  a 
few  weeks.  Man  has,  in  fact,  reverted  from  the  land- 
tied  condition  involved  in  agriculture  to  the  migratory 
habits  of  an  earlier  period  of  man's  life  on  the  earth. 
As  Wells  has  put  it:  "in  every  locality  .  .  .  countless 
people  are  delocalised,"  and  it  is  not  the  least  evil  of 


l6o       OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

urbanization  that,  in  consequence  of  this,  the  admin- 
istration of  local  affairs  falls  too  often  "  into  the  hands 
of  that  dwindling  moiety  which  sits  tight  in  one  place 
from  the  cradle  to  the  grave,"  or  of  persons  who  have 
a  financial  axe  to  grind. 

The  difficulties  of  water  supply,  of  scavenging,  and 
of  drainage,  until  they  were  overcome,  have  made 
towns  the  inevitable  destroyers  of  mankind.  The  con- 
ditions of  housing  are  worse  in  towns  than  in  country 
districts,  higher  rents  and  less  ground  space  implying 
that  each  family  on  an  average  lives  in  fewer  and 
more  crowded  rooms  than  in  rural  districts. 

Furthermore,  in  towns  there  is  greater  difficulty  in 
securing  satisfactory  arrangements  for  the  storage  of 
food,  especially  milk,  and  in  obtaining  fresh  milk  and 
vegetables ;  and  there  is  the  serious  disadvantage,  espe- 
cially for  children,  that  their  playgrounds  are  in  streets 
instead  of  the  fields,  and  that  the  possibilities  of  deriv- 
ing infection  from  dried  expectoration  and  from  faecal 
or  other  organic  contamination  in  yards  and  back- 
streets  as  well  as  directly  from  other  children  or  adults 
are  multiplied  manifold. 

Even  more  important,  town  life  for  the  father  of  a 
family  generally  means  an  indoor  and  often  a  dusty 
indoor  occupation ;  the  mother  not  infrequently  is  also 
industrially  employed;  and  these  adverse  circum- 
stances, so  far  as  they  are  allowed  to  continue,  now 
affect  three-fourths  of  the  population  of  England  and 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS        l6l 

Wales  and  probably  one-half  of  that  of  the  United 
States. 

And  yet  the  death-rate  from  all  causes,  and  espe- 
cially from  communicable  diseases  is  steadily  declining, 
to  an  even  greater  extent  in  urban  than  in  rural  com- 
munities. 

It  is  but  fair  to  add  that  the  differences  between 
urban  and  rural  populations  tend  to  decrease ;  at  least 
this  is  so  in  England ;  probably  the  same  is  true  to  a 
less  extent  in  America.  The  nominally  rural  popula- 
tion is  becoming  more  and  more  urban  in  character, 
and  composed  not  solely  of  rustics, — who  live  in  and 
by  the  soil  and  are  altogether  more  natural  in  their 
habits, — but  largely  of  town-dwellers  who  only  sleep 
in  country  dormitories.  But  this  makes  it  all  the  more 
remarkable  that  notwithstanding  the  multitudinous 
circumstances  which  have  tended  to  increase  disease, 
the  death-rate  has  been  lowered  to  an  amount  already 
indicated,  and  life  has  been  prolonged  to  an  extent 
which  has  secured  an  increase  in  its  average  expecta- 
tion of  10  or  ii  years  within  the  last  thirty  years. 

Industrialism 

Considerations  of  time  render  it  impracticable  to 
discuss  in  this  address  the  mischievous  influence  of 
modern  industrialism  on  national  health.  This  influ- 
ence runs  collaterally  with  that  of  urbanization;  and 
in  it  in  the  past  can  be  seen  the  evil  results  of  over- 

12 


1 62       OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

work,  of  dust  inhalation,  of  chemical  poisoning,  of 
industrial  infections  including  tuberculosis,  and  of  the 
general  depressing  effect  of  protracted  monotonous 
work.  The  evils  of  industrialism  like  those  of  urbani- 
zation are  happily  being  in  a  large  measure  counter- 
acted. 

Poverty 

The  problems  of  industrialism  in  relation  to  health 
cannot  be  adequately  discussed  apart  from  a  consid- 
eration of  the  remuneration  for  work,  which  neces- 
sarily depends  on  the  power  of  the  worker  to  strike  a 
satisfactory  bargain  with  his  employer,  and  the  extent 
to  which  he  can  ensure  regular  employment.  If  these 
conditions  cannot  be  fulfilled,  or  if  the  breadwinner  is 
dead  or  disabled,  poverty  results,  using  this  word  here 
in  the  sense  of  inability  to  provide  for  the  personal  and 
family  essentials  of  health.  And  here  we  are  at  once 
faced  with  the  problem  of  relation  of  population  to 
means  of  subsistence.  Malthus  in  1798  advanced  the 
pessimistic  hypothesis  that  poverty  is  the  inevitable 
result  of  increase  of  population,  which  entitles  him 
to  be  characterised  as  the  Schopenhauer  of  Political 
Economy,  as  Schopenhauer  was  the  Malthus  of  Phi- 
losophy. Without  attempting  detailed  discussion  of 
Malthus's  hypothesis,  it  is  clear  that  the  wealth  of  the 
population  depends  upon 

1.  The  amount  of  food  produced, 

2.  The  amount  of  materials  produced, 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS       163 

3.  The  efficiency  in  preparation  of  these  materials,  and 

4.  Convenience  of  transport. 

In  all  these  particulars  means  of  subsistence,  con- 
sidered internationally,  have  during  the  last  century 
grown  more  rapidly  than  population ;  and  now,  whether 
we  like  it  or  not,  a  new  element  has  entered  into  the 
problem  in  this  and  several  other  countries, — volun- 
tary control  of  births, — necessitating  the  estimation  of 
future  growth  of  population  on  a  radically  different 
basis  from  that  of  the  past,  and  banishing  the  fear  of 
poverty  as  the  result  of  too  large  a  population. 

It  may  even  become  necessary  to  adopt  some  method 
of  national  remission  of  taxation  or  subsidisation  of 
wages  in  accordance  with  size  of  the  family,  not  only 
in  France,  but  hereafter  in  England,  if  in  England,  as 
already  in  France,  the  voluntary  control  of  births  is 
practised  to  an  extent  resulting  in  a  stationary  or  even 
a  decreasing  population.  In  America  the  possible  need 
for  such  action  will  not  arise  for  several  generations, 
during  which,  however,  unless  the  present  trend  of 
events  is  changed,  Roman  Catholics  appear  likely 
largely  to  replace  Protestants,  and  the  Slavonic  and 
Irish  to  preponderate  over  the  Anglo-Saxon  elements 
of  the  population.  It  is  possible,  of  course,  that  in 
another  generation  the  Roman  Catholic  Church  may 
not  be  able  to  continue  its  ban  on  birth-control,  and 
that  the  more  "  backward  "  (  ?)  races  will  adopt  simi- 
lar devices,  including  even  the  Japanese  and  the 
Chinese. 


164      OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

*+~+3L+#  JU^w*^v-C/7  C  C  -  f  7 3 


The  Malthusian  Hypothesis 

(a)  The  Malthusian  hypothesis  has  been  held  to 
justify  the  laissez  faire,  laisses  alter  policy  which  held 
the  industrial  world  in  its  malignant  grip  during  the 
latter  part  of  the  eighteenth  and  the  earlier  part  of  the 
nineteenth  century,  and  from  which  we  are  not  yet 
completely  freed.  Workers  were  exploited  and  re- 
duced to  a  position  of  modified  slavery;  and  this  was 
assumed  by  clergy  and  political  economists  alike  to  be 
part  of  the  ordered  course  of  life.  This  doctrine  was 
made  to  support  the  belief  that  God  had  ordained  the 
poor  man's  lot,  with  its  attendant  misery  and  hope- 
lessness. 

On  page  438  of  the  sixth  edition  of  his  book  Malthus 
says: 

that  the  principal  and  most  permanent  cause  of  poverty  has 
little  or  no  direct  relation  to  forms  of  government,  or  the 
unequal  division  of  property;  and  that,  as  the  rich  do  not  in 
reality  possess  the  power  of  finding  enployment  and  main- 
tenance for  the  poor,  the  poor  cannot  in  the  nature  of  things, 
possess  the  right  to  demand  them,  are  important  truths  flow- 
ing from  the  principle  of  population. 

In  the  first  edition  of  his  book  a  more  extreme, 
plainer  statement  of  the  position,  as  assumed  by 
Malthus,  was  given,  but  was  omitted  from  later  edi- 
tions (the  extract  is  translated  by  Beale  from  a  French 
edition)  : 

A  man  born  into  the  world  already  occupied,  if  his  family 
can  no  longer  keep  him,  or  if  society  cannot  utilise  his  work, 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS        165 

has  not  the  least  right  whatever  to  claim  any  share  of  food, 
and  he  is  already  one  too  many  upon  the  earth.  At  the  great 
banquet  of  Nature  there  is  no  cover  laid  for  him.  Nature 
commands  him  to  go  and  she  is  not  long  in  putting  this  order 
herself  into  execution. 

Malthus  supplied  the  clue  which  helped  to  start  Dar- 
win on  his  epoch-making  investigations;  and  to  the 
present  day  there  are  men  who  do  not  appreciate  that 
the  mutual  aid  which  is  fundamental  in  human  society 
is  an  enemy  to  the  continued  operation  of  natural  selec- 
tion, and  that  we  cannot  revert  to  natural  selection 
without  destroying  the  characteristic  work  of  civiliza- 
tion. To  think  otherwise  is  the  secret  behind  German 
aggression ;  to  act  otherwise  is  to  revert  to  barbarism. 
Man,  has  definitely  replaced  natural  by  rational  selec- 
tion, and  wjll,  I  have  no  doubt,  to  a  steadily  increasing 
extent  replace  competition  by  cooperation. 

(&)  The  Malthusian  hypothesis  and  the  policy  based 
on  it  ignored  the  human  element  in  industry.  Hap- 
pily revolt  against  the  strict  application  of  the  laisses 
faire  policy  set  in  soon  after  urbanization  and  indus- 
trialism (under  the  then  conditions)  began  their  male- 
ficient  work,  first  in  regard  to  children,  then  for 
women,  and  latterly  more  general  in  character. 

Nothing  is  more  conspicuous  in  recent  years  than 
the  growth  of  sensibility  on  the  subject  of  economic 
evils,  especially  as  to  the  conditions  of  industry.  Eco- 
nomic efficiency,  as  a  sole  object,  appeared  to  preclude 
regard  to  morality  of  method,  and  the  result  has  been 


166       OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

poverty  for  the  masses  of  mankind.  If  this  is  to  cease, 
satisfactory  minimum  standards  of  comfort  and  wel- 
fare for  the  entire  population  must  be  accepted,  which 
will  form  a  first  charge  on  industry.  This  can  only  be 
hoped  for  when  there  is  complete  practical  acceptance 
of  the  fact  that "  we  are  members  one  of  another,"  and 
servitude  is  completely  replaced  by  the  ideal  of  mutual 
service. 

(c)  The  Malthusian  hypothesis  ignores  the  great 
though  paradoxical  truth,  that  although  under  circum- 
stances permitting  malnutrition  and  defective  training, 
large  families  spell  poverty,  especially  when  popula- 
tion is  not  distributed  where  it  is  needed,  the  real 
wealth  of  the  world  after  all  depends  on  man  himself. 
Nature  gives  him  little  that  he  can  use  in  the  form  in 
which  he  finds  it.  It  is  by  him  and  by  him  alone  that 
"  wealth  "  is  created  by  converting  useless  into  useful 
matter. 

It  appears  to  me  clear  that  over-population  need  not 
excite  apprehension;  that  population  in  itself  is  the 
only  means  by  which  national  wealth  can  materialise ; 
and  that  our  chief  aim  in  securing  national  efficiency 
must  be  to  train  each  unit  of  the  population  adequately 
for  work,  and  to  prevent  the  terrible  loss  of  efficiency 
due  to  avoidable  sickness. 

And  this  brings  me  to  the  direct  statement  of  the 
truism  that  health  progress  can  only  be  secured  by 
preventing  preventible  illness. 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS       167 

Poverty  and  disease  are  allied  in  the  closest  relation- 
ship ;  and  while  it  is  true  that  the  removal  of  poverty 
would  effect  a  great  improvement  in  national  health, 
it  is  even  truer  that  the  prevention  of  illness  forms  the 
most  important  means  for  the  avoidance  of  poverty. 

In  various  reports  it  has  recently  been  shown  that 
in  a  number  of  districts  an  inverse  correlation  exists 
between  infant  mortality  and  the  amount  of  the  family 
income;  the  implication  appearing  to  be  that  increase 
of  the  lower  income  is  the  best  and  perhaps  the  only 
method  for  obviating  excessive  loss  of  infantile  life. 

In  such  an  argument  poverty  evidently  is  consid- 
ered as  an  element,  instead  of  as  a  highly  complex 
phenomenon  needing  to  be  further  analyzed  into  its 
constituent  parts.  In  the  instance  quoted,  the  fact 
that  the  correlation  between  poverty  and  high  infant 
mortality  is  not  essential  can  be  shown  by  examples 
of  low  infant  mortality  in  communities  in  which  pov- 
erty is  the  rule ;  by  examples  of  high  infant  mortality 
in  which  wages  are  high ;  and  by  other  examples  of 
communities  in  which  high  infant  mortality  has  been 
lowered  without  any  change  in  economic  conditions. 

The  social  conscience  cannot  be  satisfied  until  every 
family  has  an  income  sufficing  for  all  its  essential 
needs ;  but  there  are  possibilities  of  successful  attack 
on  infant  mortality  which  can  be  pursued  when  eco- 
nomic change  is  not  within  reach,  and  when  such  eco- 
nomic change  would  not  obviate  the  need  for  further 


168       OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

measures.  Among  such  measures  may  be  mentioned 
the  abolition  of  alcoholism,  the  provision  of  a  pure 
and  adequate  milk-supply,  increased  attention  to  do- 
mestic and  municipal  sanitation,  health  teaching  by 
public  health  nurses,  and  prompt  and  adequate  medical 
and  nursing  assistance  when  required. 

Ignorance 

It  may  have  surprised  you  that  I  have  not  placed 
ignorance  in  the  forefront,  before  industrialism,  ur- 
banization, and  poverty,  as  the  chief  enemy  of  per- 
sonal and  public  health.  I  have  no  hesitation  in 
making  the  statement  that  although  there  is  need  for 
large  additions  to  present  educational  work  in  hygiene, 
the  utilisation  of  existing  knowledge  by  those  holding 
responsible  positions  is  even  more  important.  Is  it 
not  true  that  it  is  easier  to  promote  educational 
"drives"  for  any  single  branch  of  health  education, 
than  to  obtain  money  for  the  actual  execution  of  health 
work? 

Let  us  look  more  critically  at  educational  work  in 
hygiene.  Whose  ignorance  is  it  proposed  to  enlighten  ? 
Ignorance  is  common  to  all  classes,  and  it  is  funda- 
mentally important  that  systematic  instruction  in  phys- 
iology and  hygiene  should  be  given  in  all  our  schools ; 
and  that  especially  every  teacher  should  have  adequate 
training  in  these  subjects,  and  in  the  recognition  of  the 
common  mental  and  physical  defects  of  children.  If 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS       169 

a  course  of  instruction  were  given  for  all,  approaching 
that  which  is  given  for  public  health  nurses  at  Yale 
University,  how  much  more  hopeful  would  be  the 
prospect  of  public  health  progress,  both  in  New  and 
Old  England.  But  this  does  not  cover  the  entire 
needs  of  the  case.  Consider,  for  instance,  the  relation 
of  maternal  ignorance  to  excessive  child  mortality. 

Maternal  ignorance  is  sometimes  regarded  as  a  chief 
factor  in  the  causation  of  excessive  child  mortality. 
It  is  a  comfortable  doctrine  for  the  well-to-do  person 
to  adopt;  and  it  goes  far  to  relieve  his  conscience  in 
the  contemplation  of  excessive  suffering  and  mortality 
among  the  poor. 

This  doctrine  has  found  favour  in  occasional  official 
reports  and  in  miscellaneous  addresses.  It  embodies 
an  aspect  of  truth,  but  it  is  mischievous  when  it  im- 
plies, as  it  sometimes  does,  that  what  is  chiefly  re- 
quired is  the  distribution  of  leaflets  of  advice,  or  the 
giving  of  theoretical  instruction  as  to  matters  of  per- 
sonal hygiene. 

There  is  little  reason  to  believe  that  the  average 
ignorance  in  matters  of  health  of  the  working-class 
mother  is  much  greater  than  that  of  mothers  in  other 
classes  of  society.  Furthermore,  it  would  appear  that 
working-class  mothers  give  their  infants  the  supremely 
important  initial  start  of  breast  feeding  in  a  larger 
proportion  of  cases  than  do  the  mothers  in  other  sta- 
tions of  life. 


I7O       OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

The  mothers  in  both  classes  may  be  ignorant;  in 
both  there  is  deficient  training  in  habits  of  observation, 
especially  in  regard  to  the  beginnings  of  illness;  but 
the  mother  in  comfortable  circumstances  is  able  to 
ensure  for  her  infant  certain  advantages  which  the 
infant  of  the  poorer  mother  often  cannot  obtain. 
What  are  these? 

1.  The  well-to-do  mother  is  commonly  able  to  de- 
vote herself  to  her  infant  and  have  assistance  in  this 
duty;  the  working  class  mother  is  single-handed,  and 
has  also  to  perform,  unaided,  all  the  duties  of  her 
household,  including  the  washing  and  cooking  for  her 
husband  and  herself  and  possibly  for  several  children. 

2.  The  well-to-do  mother  is  commonly  able  to  en- 
sure that  the  milk  for  her  infant  is  purchased  under 
the  best  circumstances,  is  stored  in  a  satisfactory  pan- 
try, and  is  prepared  under  cleanly  conditions.    The 
working-class  mother  often  is  supplied  with  stale,  im- 
poverished milk,  may  have  no  pantry,  and,  except 
when  suckling  her  infant,  is  handicapped  at  every 
stage  in  the  cleanly  preparation  of  her  infant's  food. 

3.  If  the  well-to-do  mother  is  ill,  adequate  medical 
and  nursing  assistance  is  at  once  available,  and  the 
child's  welfare  can  be  safeguarded;  if  the  working- 
class  mother  is  ill,  the  child  usually  must  suffer  with 
its  mother. 

4.  If  the  child  of  the  well-to-do  mother  falls  ill, 
everything  that  good  nursing  and  medical  attendance 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS       171 

can  furnish  is  commonly  at  once  available;  for  the 
child  of  the  working-class  mother  the  state  of  matters 
is  remote  from  the  ideal.  Facilities  for  obtaining 
medical  attendance  and  nursing  vary  greatly  in  dif- 
ferent districts ;  but  in  none  are  they  satisfactory  for 
the  poor,  and  especially  for  the  classes  who  have 
limited  incomes,  but  do  not  as  a  rule  receive  skilled 
hospital  treatment,  or  avail  themselves  of  help  from 
nursing  associations.  Prompt  medical  assistance  at 
home  commonly  cannot  be  afforded  for  children  of 
wage-earners,  and  particularly  not  for  the  children  of 
unskilled  workers. 

5.  Infants  and  nursing  mothers  are  very  rapidly  in- 
fluenced by  their  environment.     This  environment  is 
complex.    The  mother  is  the  main  element  in  the  en- 
vironment of  the  infant.     If  she  is  over-worked  and 
suffers  from  chronic  fatigue  her  infant  must  suffer; 
directly,  because  the  mother's  milk  under  these  cir- 
cumstances is  liable  to  be  scanty  or  impoverished  or 
otherwise  unwholesome;  or  indirectly,  owing  to  her 
being  unable  to  give  sufficient  attention  to  her  infant. 
The  infant  of  the  well-to-do  mother  is  less  likely  to 
suffer  in  either  of  these  ways. 

6.  Not  only  are  the  milk  supply,  and  the  storage  and 
preparation  of  artificial  food,  important  parts  of  the 
environment  of  the  infant,  but  so  also  are  the  housing 
conditions  of  the  family,  and  the  sanitary  conditions 
of  the  back-yard  and  of  the  street  in  which  the  house 


172       OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

is  situate.  The  superiority  of  the  circumstances  of 
the  one  mother  and  infant  over  those  of  the  other  in 
these  respects  is  obvious. 

There  is  no  reason  to  assume  that  the  one  mother  is 
more  ignorant  than  the  other.  But  the  ignorance  of 
the  working-class  mother  is  dangerous,  because  it  is 
associated  with  relative  social  helplessness.  To  rem- 
edy this  what  is  needed  is  that  the  environment  of  the 
infant  of  the  poor  shall  be  levelled  up  towards  that  of 
the  infant  of  the  well-to-do,  and  that  medical  advice 
and  nursing  assistance  shall  be  made  available  for  the 
poor  as  promptly  as  it  is  for  persons  of  higher  social 
status. 

The  assistance  given  will  include  advice,  but  it  will 
be  the  advice  which  a  medical  practitioner  gives  to  his 
patient ;  which  a  health  visitor  or  public  health  nurse 
gives  as  to  personal  hygiene ;  and  which  a  sanitary  in- 
spector gives  to  a  householder.  It  should  include  also 
the  advice  given  by  a  trained  midwife  or  midwifery 
nurse,  who  is  in  a  favourable  position  to  secure  the 
adoption  of  her  advice  by  the  mother.  Such  advice  is 
becoming  available  to  a  steadily  increasing  extent,  but 
in  some  industrial  towns  a  majority  of  midwives  and 
midwifery  nurses  are  still  untrained  women,  who  are 
not  competent  to  give  the  best  advice. 

I  would  not  have  it  assumed  that  I  do  not  attach 
high  values  to  the  teaching  which  the  physician  gives 
to  his  patient  and  the  public  health  nurse  to  the  healthy 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS       173 

mother  and  infant;  but  unless  this  is  combined  with 
assistance  to  provide  the  necessary  means  to  health, 
whether  this  be  hospital  treatment,  home  nursing,  pure 
milk,  improved  domestic  conditions,  or  help  to  the 
over-tired  mother,  the  advice  falls  far  short  of  its 
potentialities  for  good. 

There  is  need  for  further  instruction  of  the  public 
in  all  branches  of  hygiene;  and  we  need,  if  we  are 
to  be  efficient  in  social  work,  to  follow  the  advice  of 
Oliver  Wendell  Holmes,  to  remove  the  intellectual 
membrana  nictitans  from  our  eyes,  and  to  consider  the 
physical  and  moral  as  well  as  the  intellectual  obstacles 
to  health. 
^-In  the  cultivation  of  communal  health 

Defects  of  Character 

are  even  more  pernicious  than  lack  of  knowledge.  No 
member  of  any  of  our  local  authorities  can  fail  to 
have  been  warned  that  typhoid  fever  is  still  being 
spread  in  many  communities  by  impure  water,  and  as 
the  result  of  inadequate  hospital  isolation  of  cases. 
The  means  of  prevention  of  tuberculosis  are  well 
known;  but  how  few  local  authorities  will  face  the 
problem  of  supplying  adequate  funds  for  clinics,  for 
examination  of  contacts,  for  hospitals  for  bed-ridden 
cases,  and  for  convalescent  homes;  and  how  few  are 
willing  to  give  help  to  ensure  that  the  consumptive 


174       OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

patient  has  a  separate  bedroom?  In  how  few  in- 
stances are  the  regulations  against  indiscriminate  ex- 
pectoration enforced,  and  how  seldom  are  physicians 
called  to  account  for  not  obeying  the  law  as  to  prompt 
notification  of  cases  of  tuberculosis?  Will  all  the 
"drives"  against  tuberculosis  effectually  remedy  this 
condition  of  things  ?  Would  not  public  opinion  amply 
support  the  one  "drive"  which,  above  all  others,  is 
necessary:  a  systematized  effort  on  the  part  of  all  so- 
cial workers  to  exact  a  definite  promise  from  every 
candidate  for  local  or  state  office  that  he  will  give 
earnest  support  to  all  well-considered  anti-tuberculosis 
measures,  for  the  diminution  of  venereal  diseases,  for 
improving  the  welfare  of  mothers  and  their  children, 
for  promoting  school  hygiene,  and  for  improving  the 
housing  of  the  poor.  Democratic  Government,  alas! 
hitherto,  has  meant  government  by  active  minorities. 
The  great  danger  of  democracy  is  that  the  minority 
may  and  often  does  consist  largely  of  persons  having 
a  mercenary  interest  in  the  machinery  of  local  gov- 
ernment. Why  should  not  it  become  an  active  and 
preponderant  minority  of  health  gospellers?  This 
will  involve  the  taking  of  infinite  trouble  to  overcome 
the  multiform  activities  associated  with  "political 
pull";  it  will  involve  the  watching  of  the  record  of 
each  elected  person,  merciless  exposure  of  those  who 
do  not  whole-heartedly  support  reforms,  and  system- 
atic effort  to  prevent  the  reelection  of  all  whose  record 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS       175 

proves  unsatisfactory.  Are  we  equal  to  this  task  ?  Is 
our  national  and  local  patriotism  equal  to  this  heroic 
test,  involving  most  prosaic  work,  the  surveillance  and 
the  "besting"  of  the  politician?  If  not,  our  indirect 
attack  on  the  enemy  by  means  of  special  educational 
drives  can  have  relatively  little  effect.  Where  the 
enemy  is,  there  our  fight  should  be ;  and  the  chief  ene- 
mies of  health  are  local  authorities  possessing  powers 
to  secure  health  for  the  community,  who  corruptly  or 
parsimoniously  refrain  from  their  duty.  Nor  can  we 
avoid  responsibility,  or  the  need  for  strenuous  effort 
after  efficiency  by  not  taking  part  in  official  or  volun- 
tary administrative  work.  We  may  have  sufficiently 
good  reasons  for  this  abstinence;  and  onlookers  have 
their  role  in  life.  If  all  were  authors,  where  would 
be  the  readers?  There  are  many  indifferent  writers 
who  would  be  appreciative  readers,  and  the  same  re- 
mark applies  in  local  administration.  Appreciation  is 
necessary  as  well  as  a  subject  to  be  appreciated;  and 
the  onlooker  at  social  work  may  be  most  helpful.  If 
he  is  to  be  helpful  he  must  be  kindly  and  charitable,  as 
well  as  watchful.  Rancorous  and  ill-informed  criti- 
cism must  be  avoided,  and  the  onlooker  must  be  ready 
to  do  justice  to  good  work,  or  attempted  good  work. 
Nothing  has  made  it  so  difficult  to  secure  good  men  to 
undertake  the  burden  of  local  government  as  the  un- 
discriminating  and  uncharitable  criticism  aimed  at 
those  engaged  in  it.  Criticism  of  representatives  has 


176       OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

often  been  deserved;  but  critics  are  too  often  those 
who  will  not  aid  to  the  slightest  extent  in  the  work 
which,  often  without  sufficient  knowledge  of  the  facts, 
they  villify.  When  we  read  of  administrative  scan- 
dals, it  is  desirable  to  have  a  sense  of  proportion,  and 
to  remember,  as  the  reader  of  old  records  or  even  of 
Pepys*  diary  will  scarcely  need  to  be  reminded,  that 
corruption  was  rampant  in  the  past,  and  especially  to 
remember  that  the  best  way  to  remove  that  most  subtle 
and  mischievous  form  of  corruption  which  consists  in 
giving  and  accepting  appointments  as  political  re- 
wards, is  by  ourselves  taking  a  part  in  local  govern- 
ment, or  by  steadily  upholding  those  who  are  doing  so 
with  integrity. 

The  onlooker,  then,  has  his  duty  to  perform  as  well 
as  the  administrator.  He  cannot  do  his  duty  unless 
he  intelligently  studies  local  administration,  even 
though  he  takes  no  part  in  it.  A  chief  need  is  this  in- 
terested study  of  the  phases  of  local  administration 
by  the  general  inhabitants  of  each  district.  Happily 
there  are  indications  of  the  increasing  local  patriotism 
which  such  study  implies.  The  exact  knowledge  thus 
acquired  is  the  best  means  of  neutralising  much  of 
the  ill-natured,  because  ill-informed,  criticism  with 
which  the  founts  of  local  administration  are  too  often 
fouled.  A  high  moral  ideal  on  the  part  of  onlookers 
as  well  as  of  administrators  is  needed  if  we  are  to 
secure  that  high  standard  of  social  efficiency  which  is 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS       177 

an  indispensable  condition  of  the  further  triumphs  of 
preventive  medicine  now  waiting  to  be  secured. 

Ideals 

In  my  discussion  of  the  difficulties  of  health  progress, 
I  have  evidently  encroached  here  and  there  on  the  sec- 
ond division  of  my  lay  sermon.  Let  me  now  attempt 
to  state  more  systematically  some  ideals  of  health  and 
means  for  their  realisation. 

Intelligent  human  society,  permeated  more  than  we 
realise  by  the  essentials  of  Christianity,  has  already 
gone  far  in  securing  remedies,  notwithstanding  the  too 
frequent  other-worldliness  or  lack  of  vision  of  those 
who  should  have  been  foremost  in  rebuilding  Jeru- 
salem in  this  green  and  pleasant  land.  Industrialism 
no  sooner  huddled  together  labourers  and  their  fami- 
lies in  the  courts  and  alleys  of  insanitary  towns  and 
overworked  them  for  scanty  wages,  than  the  voices  of 
such  philanthropists  as  Percival,  Oastler,  Shaftesbury, 
Owen,  and  of  many  others  were  heard  in  favour  of 
interference  with  that  freedom  (!)  of  contract  be- 
tween workers  and  employers,  which  the  professors 
of  the  dismal  science  regarded  as  a  fundamental  prin- 
ciple in  political  economy.  And  so  gradually,  too 
slowly,  regulated  industry,  improved  sanitation,  better 
housing,  the  isolation  and  hospitalisation  of  infectious 
cases,  the  readier  access  than  in  rural  districts  of  all 

13 


178       OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

sick  to  skilled  treatment,  higher  wages,  better  food 
began  to  counteract  the  evils  of  industrialism  and 
urbanization.  Communal  action  was  taken  in  the 
regulation  of  industry,  in  the  promotion  of  sanitation, 
in  providing  elementary  education;  and  the  result  is 
seen  in  the  remarkable  fact  that,  notwithstanding  its 
enormous  handicap,  urban  life  has  become  almost  as 
safe  as  rural  life,  so  far  as  life  itself  is  concerned, 
though  not  in  standard  of  health. 

The  first  lesson,  then,  which  has  already  been  par- 
tially learnt,  is  that  no  member  of  a  community  can 
live  to  himself.  We  now  believe  in  the  solidarity  of 
society ;  that  the  sores  of  one  section  of  it  means  peril 
for  all.  And  we  are  gradually  learning  to  appreciate 
that  this  is  true  not  only  in  respect  of  the  acute  infec- 
tious diseases,  and  of  chronic  infectious  diseases,  such 
as  tuberculosis  and  syphilis,  but  of  every  disease  and 
of  every  other  factor  in  life  which  causes  individual 
inefficiency,  and  which  consequently  inflicts  additional 
burdens  on  the  competent  section  of  the  community. 
I  do  not  wish  to  underestimate  the  basic  self-centred- 
ness,  if  not  actual  selfishness,  which,  to  a  varying  ex- 
tent, is  part  of  the  nature  of  all  of  us ;  but  in  industrial, 
as  in  other  social  problems,  whatever  may  be  the  inter- 
mediate turmoil  and  misunderstandings  and  disturb- 
ance which  appear  to  loom  so  threateningly,  it  is  plain 
that  the  mere  cash  nexus  of  relationship  is  becoming 
more  and  more  entagled  in  a  moral  nexus ;  and  that  a 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS       179 

prophet's  vision  is  scarcely  needed  to  forecast  a  future 
of  consolidation  and  conformity  of  efforts  of  employ- 
ers and  employed  such  as  has  never  yet  been  generally 
realised.  In  such  a  consolidation  the  idea  of  servitude 
will  disappear,  and  mutual  service  will  take  its  place. 
This  will  happen  by  the  growth  of  an  idealistic  stand- 
point; even  more,  perhaps  through  motives  of  com- 
munity self-defence. 

Secondly,  the  Great  War,  though  the  most  terrible 
calamity  to  humanity  of  the  ages,  has  brought  out  a 
most  comforting  and  elevating  thought.  Our  brothers 
and  our  sons, — and  our  daughters  also  in  a  multitude 
of  munition  and  other  works, — have  proved  that,  under 
the  overwhelming  moral  compulsion  of  national  need, 
they  are  willing  and  ready  to  lay  down  their  lives  for 
great  impersonal  things,  and  in  their  hundreds  of  thou- 
sands they  have  done  so.  Coincidently  with  this,  a 
great  impetus  has  been  given  to  work  for  the  health 
and  welfare  of  the  civilian  population,  and  especially 
of  mothers  and  their  children.  The  removable  horrors 
and  losses  of  peace,  in  the  aggregate,  are  greater  than 
those  of  war.  Cannot  an  equal  spirit  of  sacrifice  be 
induced  against  these?  Is  it  not  possible  to  evoke  a 
like  devotion  to  secure  the  triumph  of  good  over  evil, 
of  clean  administration  over  political  pull,  of  fair  deal- 
ing over  industrial  exploitation,  of  adequate  output 
over  "  slacking,"  of  determination  to  spend  and  be 
spent  to  secure  the  welfare  of  all,  in  peace  as  in  war? 


l8o      OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

Thirdly,  prior  to  the  war,  for  years,  many  among  us 
had  been  realising  to  an  increasing  extent  the  supreme 

importance  of  the  Mother  and  the  Child,  in  saf  eguard- 

>*-  ••  •  <*•  ~~  _  i          .  -  -        »          •!'• 

ing  family  life,  and  in  securing  the  beginnings  of  per- 
sonal and  national  health.  In  past  years  medical  offi- 
cers of  health  have  been  busily  occupied  in  struggling 
to  overcome  epidemic  diseases,  and  in  attacking  the 
circumstances  favouring  their  prevalence.  But  for 
twenty  years,  at  least,  the  outlook  has  widened;  the 
physiological  as  well  as  the  pathological  aspects  of 
hygiene  have  received  attention ;  and  it  has  been  real- 
ised, more  and  more,  that  in  the  conservation  and 
upbuilding  of  the  health  of  the  infant  and  the  pre- 
school child  rests  the  chief  hope  of  the  future;  and 
somewhat  more  recently,  public  health  policy  has  di- 
rected itself  to  the  protection  of  motherhood,  on  which 
depends  essentially  the  welfare  of  the  child. 

This  can  only  be  done  by  ensuring,  chiefly  through 
its  mother,  for  every  newcomer  on  the  stage  of  life,  in 
all  essential  points,  a  footing  of  equality  of  opportunity, 
physical,  mental,  and  moral,  with  all  others. 

The  ideal  that  every  child  should  have  equality  of 
opportunity  is  really  part  of  a  general  upward  move- 
ment in  our  national  ethical  life. 
The  thoughts  of  men  are  widened  with  the  process  of  the  suns. 

We  begin  to  appreciate  the  full  significance  of  the 
older  words,  "  it  is  not  the  will  of  your  Father  that  one 
of  these  little  ones  should  perish";  and  this  ideal 


OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS       l8l 

happily  is  now  certain  to  replace  the  materialistic  doc- 
trine of  the  German  type  which  drives  the  weaker  to 
the  wall. 

Progress  has  been  slow;  but  when  we  recall  how 
true  it  was  in  St.  Paul's  day  that  "the  whole  creation 
groaneth  and  travaileth  in  pain  together  until  now"; 
and  how  gradually  through  the  ages  the  mass  of  hu- 
man suffering  has  been  abated,  we  can,  while  regretting 
the  slow  rate  of  progress,  gain  encouragement  for 
more  rapid  future  advance.  The  abolition  of  slavery, 
the  higher  position  of  women,  the  steadily  increasing 
force  leading  towards  one  standard  of  sexual  morality 
for  both  sexes,  the  improved  conditions  of  housing  and 
sanitation  notwithstanding  the  impediments  of  urban 
life,  and  the  increasingly  humanitarian  conditions  of 
modern  industrialism,  all  give  us  reason  to  lift  up  our 
hearts. 

There  have  been  three  stages  in  the  attitude  of  man- 
kind to  altruistic  work.  The  first  of  these  is  illus- 
trated by  the  attitude  of  the  father  who  said  to  his 
son :  "  Learn,  my  son,  to  bear  tranquilly  the  calamities 
of  others."  Is  not  the  second  stage,  illustrated  by  the 
sleeping  disciples  in  the  Garden  of  Gethsemane,  igno- 
rant or  regardless  of  the  impending  tragedy;  while 
the  third  stage  is  manifest  in  the  thousands  of  earnest 
social  workers, — and  the  supremely  important  consci- 
entious members  of  our  governing  bodies  come  in  this 
group, — who  are  endeavouring  to  secure  the  realisa- 


1 82       OBSTACLES  TO  AND  IDEALS  OF  HEALTH  PROGRESS 

tion  in  communal  practice  of  every  measure  for  uplift- 
ing mankind. 

It  is  well  for  mankind  that  the  Mother  and  the 
Child  have  become  the  foundation  on  which,  more  and 
more,  we  expect  health  progress  to  be  built. 

A  child  more  than  all  other  gifts 

That  earth  can  offer  to  declining  man 

Brings  hope  with  it  and  forward  looking  thoughts. 

(Wordsworth.) 

The  history  of  the  Mother  and  Child  summarises  the 
history  of  the  uplifting  of  mankind:  and  although 
there  are  not  lacking  sinister  elements  in  the  present 
position,  it  is  a  great  gain  that  both  in  regard  to  the 
Mother  and  Child  and  to  the  saving  of  life  and  im- 
provement of  national  health  generally,  we  are  begin- 
ning to  realise  that  this  is  not  merely  a  question  of 
self-interest,  personal  or  national ;  but  that  we  are  con- 
cerned also  with  duty,  and  honour,  and  chivalry. 


CHAPTER  VIII 


I  use  the  word  Poverty,  for  the  purpose  of  this  dis- 
cussion, as  meaning  Destitution,  in  the  sense  of  lack 
of  means  to  provide  some  specific  requirement,  indis- 
pensable for  the  health  of  the  family,  or  the  individual. 

Such  poverty  is  evidently  undesirable  and  mis- 
chievous, from  the  point  of  view  of  both  rich  and 
poor ;  and  I  think  we  shall  agree  that,  given  the  adop- 
tion of  the  requisite  measures,  its  continuance  in  most 
instances  is  unnecessary.  Hence  the  real  subject  for 
discussion  is,  how  poverty  may  be  diminished  and 
prevented. 

I  do  not  propose  to  touch  on  the  important  subjects 
of  unemployment,  of  under-employment,  or  of  the  re- 
lation between  the  size  of  family  and  poverty,  though 
the  last  named  of  these  opens  up  an  interesting  subject 
of  discussion.  (On  this  see  page  164.)  I  shall  confine 
my  remarks  to  the  very  obvious  relation  between  pov- 
erty and  sickness,  and  to  the  neglect  to  act  on  our 
present  knowledge,  which  if  acted  on  would  in  a  short 
time  lead  to  a  great  reduction  of  poverty  in  our  midst. 

1  An  address  to  the  Political  Economy  Club,  Johns  Hopkins 
University,  Jan.  19,  1920. 

183 


1 84          SOME  ASPECTS  OF  POVERTY 

There  is  much  truth  in  each  of  the  statements  that 
poverty  is  responsible  for  much  disease,  that  disease  is 
responsible  for  the  greater  part  of  the  total  poverty  in 
our  midst,  and  that  poverty  begets  poverty. 

Poverty  and  disease  are  allied  by  the  closest  bonds, 
and  nothing  can  be  simpler  or  more  certain  than  the 
statement  that  the  removal  of  poverty  would  effect  an 
enormous  reduction  of  disease.  The  removal  of  pov- 
erty must,  therefore,  be  in  itself  an  object  always  fas- 
cinating to  those  whose  study  is  the  public  health. 
The  diseases  which  would  be  reduced  by  this  means, 
include  not  merely  those  which  physicians  treat,  but 
many  moral  diseases  which  persist  because  they  are 
only  to  be  avoided  by  the  poor  through  the  exercise  of 
discipline  and  self-restraint  far  beyond  what  is  prac- 
tised by  the  average  person  in  classes  not  subject  to 
poverty.  The  happiness  of  a  community  being  in  it- 
self a  desirable  object,  a  national  asset,  it  is  also  not 
irrelevant  to  consider  that  the  removal  of  poverty 
involves  enlarged  opportunities  for  enjoyment  which, 
rightly  directed,  would  be  only  of  less  value  than  the 
removal  of  disease.  It  is  not  surprising,  therefore, 
that  the  first  impulse  of  a  student  of  the  public  well- 
being,  in  which  the  public  health  is  the  most  important 
factor,  is  to  attack  disease  by  demanding  the  reduction 
of  poverty,  with  its  more  or  less  inevitable  accompani- 
ments of  overfatigue,  privation,  overcrowding,  and 
dirt.  And  it  must  be  freely  admitted  that  when  the 


SOME  ASPECTS  OF  POVERTY          185 

most  active  public  health  administration,  including 
adequate  medical  aid  for  the  sick,  has  attained  its  ut- 
most efficiency,  and  has  in  every  respect  done  all  that 
it  can  to  reduce  disease,  there  will  still  remain  a  cruel 
residuum  which  can  be  attacked  in  no  other  way  than 
by  the  removal  of  poverty,  or  by  the  removal  from 
poverty  of  the  elements  of  personal  privation  which 
affect  the  public  health. 

The  importance  attached  to  poverty  as  a  cause  of 
illness  and  mortality  is  illustrated  in  reports  on  local 
investigations,  displaying  an  inverse  relationship  in 
different  communities  between  family  income  and  the 
rate  of  infant  mortality,  the  reader  being  left  to  infer, 
that  increase  of  the  lower  incomes  is  the  one  method 
for  obviating  excessive  loss  of  infantile  life.  In  sug- 
gesting this  crude  generalization  it  is  evident  that  pov- 
erty is  being  regarded  as  an  element,  instead  of  as  a 
highly  complex  phenomenon,  which  needs  to  be  further 
analysed  into  its  constituent  parts.  The  crude  gener- 
alised statement  as  to  the  relation  between  excessive 
mortality  and  poverty,  furthermore,  fails  to  bring  out 
three  essential  points,  viz.,  that  infant  mortality  may 
be  very  low  in  communities  in  which  poverty  is  the 
rule;  that  it  may  be  high  in  the  absence  of  poverty; 
and  that  where  infant  mortality  is  high,  it  can  be 
greatly  reduced  without  change  of  economic  conditions. 

There  should  be  an  adequate  family  income  for 
every  family ;  and  the  social  conscience  cannot  be  sat- 


1 86          SOME  ASPECTS  OF  POVERTY 

isfied  until  this  is  realised.  But,  in  seeking  for  prac- 
tical reform  we  must  appreciate  that  a  large  share  of 
the  disease  and  of  the  inefficiency  of  the  individual  and 
family  associated  with  poverty  can  be  remedied  other- 
wise than  by  an  increase  of  the  family  income.  This 
is  shown  by  national  and  international  experience. 
The  death-toll  on  infant  life  is  very  much  lower  in 
Norway  and  in  Ireland — both  relatively  poor  coun- 
tries— than  in  England.  Poverty  in  these  instances 
evidently  has  less  weight  than  the  favorable  factors 
of  rural  life  and  natural  feeding.  A  like  discrepancy 
in  experience  of  infant  mortality  is  seen  between  the 
experience  of  towns,  and  of  wards  in  the  same  town, 
with  approximate  equality  as  regards  poverty.  Simi- 
larly in  England  the  infants  of  miners  with  relatively 
high  wages  suffer  a  higher  mortality  (160  per  1,000 
births  in  1911)  than  the  infants  of  textile  operatives 
(148)  with  relatively  low  wages;  while  the  latter  suffer 
more  than  the  infants  of  agricultural  labourers  (97). 
These  instances  at  once  suggest  that  some  conditions 
in  town  life  play  an  important  part  in  causing  excessive 
infant  mortality;  that  in  towns  insanitary  conditions 
and  habits  of  life  are  even  more  injurious  than  the 
absence  from  home  of  the  industrially  employed 
mother;  and  that  the  causation  of  infant  mortality  is 
complex,  and  its  prevention  necessitates  a  multifarious 
attack  on  social  and  industrial  evils,  the  character  of 
this  attack  necessarily  varying  in  different  localities, 


SOME  ASPECTS  OF  POVERTY          187 

in  accordance  with  the  incidence  of  these  evils.  That 
the  influence  of  urban  life  in  causing  excessive  mor- 
tality can  be  counteracted  is  shown  by  the  varying 
mortality  in  different  urban  communities,  and  in  dif- 
ferent parts  of  the  same  town. 

We  may  in  a  given  instance  be  totally  unable  to  in- 
crease the  family  income ;  but  the  family's  present  ex- 
penditure may  be  more  satisfactorily  distributed;  and 
some,  at  least,  of  the  constituent  elements  of  poverty 
producing  excessive  child  mortality  can  be  obviated. 
We  know,  indeed,  that  this  can  be  done.  The  fact 
that  in  the  United  States  no  part  of  the  family  income 
can  be  spent  on  alcoholic  drinks,  implies  the  removal 
from  multitudes  of  families  of  the  demoralising  influ- 
ences associated  with  alcoholism,  which  are  unfavour- 
able to  the  health  of  adults  and  children  alike. 

Similarly,  increased  attention  to  domestic  and  mu- 
nicipal sanitation  and  to  the  provision  of  a  pure  and 
adequate  milk  supply,  the  health  teaching  given  by 
public  health  nurses,  and  the  prompt  medical  and  hy- 
gienic guidance  at  Child  Welfare  Centres  are  having 
an  important  influence  in  the  same  direction.  Work 
on  these  medical  and  sanitary  lines,  for  both  adults 
and  children,  comes  legitimately  within  the  sphere  of 
the  work  of  Public  Health  Authorities,  provided  out 
of  rates  and  taxes. 

It  may  be  urged  that  such  provision,  after  all,  means 
supplementation  of  the  family  income  at  the  public  ex- 


1 88          SOME  ASPECTS  OF  POVERTY 

pense.  It  is  more  properly  to  be  regarded  as  a  meas- 
ure of  insurance  against  contingencies  by  which  every 
member  of  the  community  is  benefited;  for  we  are 
each  and  all  concerned  in  the  efficiency  of  every  other 
member  of  the  community.  We  are  members  one  of 
another.  The  objection  stated  above  has  no  greater 
validity  than  an  argument  similarly  advanced  against 
the  provision  of  police  protection  or  of  sanitary  meas- 
ures out  of  public  funds. 

Elementary,  and  to  some  extent  secondary  and  uni- 
versity, education  are  regarded  as  not  only  the  legiti- 
mate subjects  of  communal  provision,  but  also  as  in- 
capable of  being  provided  satisfactorily  by  each  indi- 
vidual family ;  and  this  view  applies  with  even  greater 
force  to  the  provision  of  hospitals  and  expert  medical 
assistance,  of  nursing  assistance,  and  of  such  addi- 
tional occasional  domestic  service  as  is  required  to 
maintain  the  functional  integrity  of  the  family. 

I  have  given  the  above  as  a  special  instance  of  the 
contention  that  poverty  is  a  complex,  including  a  num- 
ber of  elements,  and  that  it  is  our  duty  to  ascertain  in 
each  area  by  careful  local  inquiry  what  are  these  con- 
stituent elements,  and  if  practicable  their  relative 
weight;  and  then  to  apply  the  most  urgently  needed 
remedies,  not  contenting  ourselves  with  the  relatively 
useless  generalisation  that  the  evils  we  see  are  ascrib- 
able  to  poverty. 

I  lay  special  stress  on  the  provision  of  skilled  med- 


SOME  ASPECTS  OF  POVERTY          189 

ical  advice  and  treatment,  and  of  nursing  assistance 
at  the  public  expense,  which  at  present  are  sorely  defi- 
cient for  the  vast  majority  of  the  population,  and  per- 
haps for  none  more  so  than  for  the  less  well-to-do 
people  who  receive  salaries  and  not  weekly  wages. 
This  assistance  possesses  the  special  advantage  previ- 
ously pointed  out,  that  it  does  not  tend  to  create  a  de- 
mand for  further  assistance,  when  such  assistance  is 
not  required. 

The  greatest  bulk  of  poverty  is  due  d;rectly  to  sick- 
ness. A  vast  mass  of  sickness  still  occurs,  which  is 
not  owing  to  lack  of  family  or  communal  means,  but 
is  due  to  ignorance  or  neglect  on  the  part  of  the  indi- 
vidual, of  the  responsible  owners  of  houses,  of  the 
employers  of  work-people,  and  still  more  of  the  mem- 
bers of  local  authorities  or  state  legislatures.  Typhoid 
fever  still  commonly  prevails  as  the  result  of  neglected 
sanitation;  hookworm  disease  still  causes  incapacity 
of  hundreds  of  thousands  for  the  same  reason;  mala- 
ria, still  one  of  the  greatest  scourges  of  humanity, 
might  be  reduced  to  a  fraction  of  its  present  amount 
if  each  community  and  each  person  would  carry  out 
available  simple  preventive  measures;  tuberculosis  is 
still  spread  throughout  every  civilized  community 
chiefly  because  indiscriminate  expectoration  is  unregu- 
lated, and  satisfactory  and  acceptable  hospital  treat- 
ment is  not  provided  for  all  those  who  need  it.  And 
so  we  continue  to  allow  avoidable  poverty  to  be  per- 
petuated, and  to  impose  not  only  on  the  sick  poor  them- 


I  OX)          SOME  ASPECTS  OF  POVERTY 

selves,  but  also  on  the  efficient  and  solvent  part  of  the 
community  a  heavy  burden,  the  removal  of  which 
would,  to  an  almost  incredible  extent,  increase  the 
general  happiness  of  mankind. 

The  relief  of  poverty  is  at  the  best  an  inefficient  and 
expensive  remedy.  It  is  seldom  adequate,  and  it  has 
few  preventive  elements.  The  prevention  of  poverty 
by  prevention  of  the  illness  causing  it,  and  by  early 
and  satisfactory  treatment  of  such  illness  as  fails  to 
be  prevented  is  the  only  efficient,  as  well  as  in  the  long 
run  the  only  economical  plan  of  campaign.  Money  in- 
surance against  sickness  has  its  place  as  a  means  of 
alleviating  the  results  of  poverty.  But  it  is  not  an  aid 
to  its  prevention ;  under  any  existing  system  of  insur- 
ance the  money  payment  is  insufficient  and  definitely 
limited  in  duration.  Although  such  relief  is  useful, 
it  is  totally  unsatisfactory  when  not  linked  up  with  a 
complete  system  of  hygienic  measures,  and  when  not 
associated  with  adequate  medical  treatment  and  nurs- 
ing. For  the  linking  of  treatment  provided  largely 
out  of  public  funds  with  insurance  there  is  no  justi- 
fication, and  it  is  contrary  to  the  public  interest ;  and 
it  is  unfortunate  that  monetary  insurance  has  been 
provided  in  England  for  a  section  of  the  population 
under  these  unsatisfactory  conditions,  thus  diverting 
expenditure  from  the  public  health  services  in  which 
it  was  urgently  needed,  and  in  which  its  use  would  at 
once  have  been  fruitful  in  increased  health  and  hap- 
piness. 


CHAPTER  IX 

THE  CAUSATION  OF  TUBERCULOSIS  AND  THE  MEASURES 
FOR  ITS  CONTROL  IN  ENGLAND1 

My  task  is  to  attempt  to  give  a  bird's-eye  view  of 
"The  Methods  of  Controlling  Tuberculosis  in  Eng- 
land," and  to  revaluate,  as  far  as  is  practicable,  in  the 
light  of  many  years'  study  of  the  disease,  the  relative 
value  of  the  measures  which  historically  have  been 
followed  by  the  greatly  reduced  mortality  from  tuber- 
culosis. The  subject  teems  with  difficulties,  and  as 
you  are  aware  there  is  no  unanimity  of  opinion  when 
tuberculosis  is  thus  considered.  This  is  the  more  sur- 
prising in  view  of  our  present  accurate  knowledge  of 
the  pathology  of  disease  caused  by  bovine  and  human 
tubercle  bacilli,  and  in  view  of  the  fairly  general  una- 
nimity of  opinion  as  to  the  methods  of  control  which 
are  needed  to  secure  still  more  rapid  reduction  of  the 
devastations  of  tuberculosis.  This  general  opinion 
may,  I  think,  be  summarised  in  the  statement  which  I 
have  made  elsewhere,  that  the  removal  or  diminution 
of  infection  from  each  single  case  of  tuberculosis 
reduces  correspondingly  the  prospect  of  further  cases, 

JThe  substance  of  two  lectures  at  the  Summer  School  on 
Tuberculosis,  Trudeau  Sanatorium,  Saranac,  N.  Y.,  July,  1919. 

191 


192 


THE   CAUSATION   OF  TUBERCULOSIS 


but  that  tuberculosis  will  not  be  completely  controlled 
until  every  tuberculous  patient  receives  such  care 
throughout  the  whole  course  of  his  life,  as  will  ensure 
his  welfare  and  will  obviate  the  likelihood  of  his  in- 
fecting others. 

It  is  noteworthy  that  the  English  death-rate  from 
pulmonary  tuberculosis — which  is  responsible  for  71 
per  cent,  of  the  total  mortality  from  tuberculosis,  and 
which  is  practically  always  due  to  infection  from  a 
human  source, — declined  in  males  between  1871-75 
and  1876-80  by  7.2  per  cent.;  in  the  next  quinquen- 
nium by  9.8  per  cent. ;  between  1881-85  and  1886-90 
by  8.3  per  cent. ;  in  the  next  quinquennium  by  9.5  per 
cent.;  between  1896-1900  and  1901-05  by  7  per  cent.; 
and  between  1901-06  and  1906-10  by  9.7  per  cent. 
Evidently  a  large  share  of  the  reduction  of  the  death- 
rate  from  phthisis  occurred  before  it  was  generally  re- 
garded as  an  infectious  disease,  and  before  sanatoria 
were  in  existence  for  its  treatment.  It  should  be 
added  that  since  the  possibilities  of  infection  have  been 
realised  and  the  need  for  treatment  of  the  disease  has 
been  appreciated,  there  has  in  no  part  of  the  world, 
so  far  as  I  am  aware,  been  an  adequate  application  of 
known  methods  of  prevention  and  treatment. 

We  must  look  elsewhere,  therefore,  than  to  inten- 
tional measures  directed  against  tuberculosis  for  an 
explanation  of  its  decline  during  the  period  before 
Koch  discovered  the  tubercle  bacilli  and  before  the 


THE   CAUSATION    OF   TUBERCULOSIS  193 

significance  of  this  discovery  was  appreciated;  and 
attempt  to  appreciate  the  relative  value  of  the  factors 
of  decline  operating  before  and  since  our  outlook  on 
the  disease  was  fundamentally  changed. 

Certain  facts  stand  out  beyond  controversy,  and 
on  these  administrative  control  must  necessarily  be 
based. 

Basic  Facts  as  to  Tuberculosis 

1.  Tuberculosis  is  a  chronic  infectious  disease  with 
a  low  degree  of  infectivity.     Circumstances  favouring 
infection  have  a  high  degree  of  importance ;  but  tuber- 
culosis does  not  develop  in  the  absence  of  the  tubercle 
bacillus.     No  infection,  no  disease. 

2.  Tuberculosis  may  remain  latent  in  the  system  for 
many  years,  and  there  is  strong  reason  for  thinking 
that  the  infection  of  a  large  proportion  of  early  adult 
tuberculosis  was  acquired  in  childhood. 

3.  The  two  types  of  tubercle  bacilli,  bovine  and  hu- 
man, are  stable  both  in  character  and  in  degree  of 
virulence,  and  are  not  interchangeable  so  far  as  can 
be  shown  by  protracted  experimentation.     The  hu- 
man type  of  bacillus  is  the  chief  source  of  infection  of 
mankind,  though  bovine  infection  is  not  negligible. 

Out  of  98  children  between  the  age  of  2  and  10  years 

who  had  died  in  various  hospitals  from  all  causes  un- 

selected,  18  or  18.4  per  cent,  were  found  to  have  been 

infected  by  tubercle  bacilli  of  the  bovine  type,  and  81 

14 


194  THE   CAUSATION   OF  TUBERCULOSIS 

or  81.6  per  cent.  t>y  tubercle  bacilli  of  the  human  type. 
(Report  on  Investigations  made  in  the  Laboratory  of 
the  Local  Government  Board,  Annual  Report  of  the 
Medical  Officer  of  the  Local  Government  Board, 
1913-14,  p.  lix.) 

4.  Animal  experimentation  shows  that  in  animals  of 
the  same  species  the  extent  of  tuberculosis  produced 
depends  to  a  large  and  probably  to  a  dominant  extent 
on  the  number  of  tubercle  bacilli  introduced  into  the 
system.    Although  doubtless  there  are  variations  in 
susceptibility  in  families,  and  in  each  individual  at  dif- 
ferent periods,  there  is  little  doubt  that  in  the  main 
the  same  rule  holds  good  for  mankind. 

5.  Experience  shows  that  dusty  occupations,  indoor 
occupations,   alcoholism,   over-fatigue,   an   attack   of 
acute  illness,  especially  of  influenza,  measles,  or  enteric 
fever,  increase  the  danger  of  minimal  doses  of  tubercle 
bacilli,  and  serve  to  bring  latent  foci  of  disease  into 
activity. 

Explanations  of  the  Decreasing  Death-rate  from 
Tuberculosis 

In  the  light  of  the  above  facts,  how  is  the  steady 
and  continuous  decline  in  the  death-rate  from  tuber- 
culosis during  the  last  fifty  years  to  be  explained? 

(a)  No  support  is  given  by  animal  experiment  to 
the  assumption  that  the  types  of  human  bacillus  infect- 
ing mankind  have  declined  in  virulence;  and  changes 


THE   CAUSATION   OF  TUBERCULOSIS  195 

in  the  severity  of  consumption  historically  or  currently 
in  different  races  of  mankind  are  equally  explicable  on 
the  ground  of  differences  in  social  misery,  in  sanitary 
conditions  and  associated  heavier  dosage  of  infection 
and  neglect  of  treatment. 

(&)  The  facts  do  not  appear  to  me  to  be  reconcil- 
able with  the  assumption  that  natural  selection  has 
increased  human  resistance  to  infection  by  tubercu- 
losis ;  though,  were  this  so,  it  would  not  justify  refrain- 
ing from  every  possible  effort  to  control  infection  and 
to  treat  every  tuberculous  patient  by  the  best  known 
methods.  Tuberculosis  is  an  ancient  disease,  there 
being  evidence  of  it  in  Egyptian  mummies  1000  years 
B.C.;  and  any  selective  agency  has,  therefore,  had 
ages  for  its  operation.  If  the  steady  decline — approx- 
imating 2  per  cent,  per  annum  in  the  death-rate  from 
pulmonary  tuberculosis  in  England  during  the  last 
thirty  or  forty  years — has  resulted  from  the  acquire- 
ment of  racial  immunity,  it  is  remarkable  that  a  some- 
what similar  decline  has  occurred  almost  simulta- 
neously during  the  last  forty  years  in  Great  Britain, 
Germany,  and  America;  while  in  France,  Norway, 
and  Ireland  there  has  been  little  if  any  decline,  or  it 
has  occurred  only  in  very  recent  years. 

To  assume  that  susceptibility  to  the  tubercle  bacillus 
in  the  course  of  its  natural  history  has  diminished  in 
England,  and  that  Ireland  has  not  shared  in  this  privi- 
lege would  be  to  add  one  more  to  Irish  grievances ! 


196  THE    CAUSATION    OF   TUBERCULOSIS 

This  assumption  does  not  fit  in  with  international  facts ; 
which  point  rather  to  the  conclusion  that,  during  the 
period  in  question,  unsatisfactory  sanitary  and  social 
circumstances,  including  opportunities  for  massive  and 
protracted  infection,  have  continued  to  a  greater  extent 
and  for  a  longer  time  in  Ireland  and  France  than  in 
Great  Britain,  America  and  Germany. 

(c)  If  the  assumption  of  increasing  racial  immunity 
does  not  consist  well  with  all  the  facts,  more  perhaps 
can  be  said  in  favour  of  the  unproved  hypothesis  that 
a  high  proportion  of  the  population  are  from  time  to 
time  temporarily  immunized  by  small  doses  of  tubercle 
bacilli ;  and  their  resistance  to  larger  doses  of  infection 
thereby  increased.  Experimentally  calves  inoculated 
with  small  doses  of  tubercle  bacilli  remain  during  the 
next  year  or  two  unaffected  by  much  larger  doses  of 
tubercle  bacilli,  unlike  calves  not  submitted  to  this 
treatment.  Tubercle  bacilli  are  somewhat  widely  dis- 
tributed, though  they  occur  chiefly  in  the  immediate 
environment  of  careless  consumptive  patients;  and  it 
is  conceivable  that  minimal  doses  of  bacilli  may  arouse 
the  resistance  of  the  cells  and  fluids  of  the  body  and 
prepare  them  to  resist  successfully  larger  doses  of 
infection.  This  is  consistent  with  the  fact  that  while 
one  in  about  ten  deaths  from  all  causes  is  caused  by 
tuberculosis,  a  majority  of  the  total  population  are 
shown  by  pathological  evidence  to  have  been  at  one 
time  or  another  infected  by  tuberculosis,  and  yet  have 


THE   CAUSATION   OF   TUBERCULOSIS  197 

either  never  been  ill,  or  have  recovered,  usually  with- 
out the  existence  of  tuberculosis  being  detected  or 
even  suspected.  Obviously  this  is  satisfactory  evi- 
dence that  mankind  is  relatively  resistant  to  the  infec- 
tion of  tuberculosis. 

The  fact  just  mentioned  naturally  leads  to  the  ques- 
tion :  what  determines  the  result  when  tubercle  bacilli 
invade  the  human  subject?  Assuming  fairly  uniform 
virulence  of  tubercle  bacilli,  the  result  for  an  infected 
person  depends  on  two  factors:  the  dosage  of  infec- 
tion, and  the  resistance  of  the  cells  and  fluids  of  the 
invaded  person;  and  evidently  increase  in  the  dosage 
of  infection  and  lowering  of  personal  resistance  may 
have  identical  effect  in  determining  serious  disease. 
Of  the  importance  of  the  already  mentioned  factors 
which  lower  personal  resistance  to  disease, — often  also 
at  the  same  time  increasing  infection, — there  can  be 
no  doubt. 

It  is  impossible  in  most  instances  to  set  out  sepa- 
rately circumstances  increasing  infection  from  circum- 
stances lowering  resistance.  During  the  last  three  or 
four  decades  there  has  been  improvement  in  respect 
of  the  factors  lowering  resistance  to  attack,  but  there 
has  been  simultaneously  a  great  decline  in  opportuni- 
ties for  infection  on  a  massive  scale,  as  a  result  of 
habits  of  greater  cleanliness,  especially  in  regard  to 
spitting,  of  diminished  overcrowding  of  population, 
and  of  increased  treatment  and  the  incidental  segre- 
gation of  advanced  cases  of  disease  in  hospital  beds. 


198  THE   CAUSATION   OF  TUBERCULOSIS 

Hospital  Treatment  of  Consumptives 
I  have  seen  no  reason  for  revoking  the  conclusion 
expressed  in  1908  in  a  lecture  to  the  Washington  Inter- 
national Congress  on  Tuberculosis  that  historically  the 
hospital  treatment  and  coincident  segregation  of  pa- 
tients suffering  from  pulmonary  tuberculosis  has  been 
an  important  and  probably  a  dominant  factor  in  pro- 
ducing the  national  decline  in  the  death-rate  from  tu- 
berculosis in  the  countries  in  which  a  decline  has  been 
experienced.  This  explanation  fits  in  with  our  know- 
ledge of  the  disease,  and  with  the  analogous  history  of 
leprosy;  and  it  is  supported  by  the  fact  that  by  com- 
plete segregation  of  infected  from  non-infected  cattle 
tuberculosis  can  be  eliminated  at  will  from  a  herd  of 
cattle.  It  is  remarkable,  as  I  have  elsewhere  set  out 
in  much  detail,  that  improved  general  health,  increased 
well-being',  and  sanitary  education  have  operated  in 
Great  Britain,  Germany,  Belgium,  Denmark,  and  Mas- 
sachusetts side  by  side  with  great  decrease  in  the  death- 
rate  from  pulmonary  tuberculosis;  while  up  to  very 
recent  years  the  same  influences  in  France,  Norway, 
and  Ireland  have  produced  little  or  no  decrease  in  the 
national  death-rate  from  tuberculosis.  And  similarly 
no  constant  relation  can  be  shown  between  the  degree 
of  sanitary  and  social  well-being  in  different  countries 
and  cities,  and  the  amount  of  mortality  imposed  by 
tuberculosis.  How  is  it  that  in  some  countries  a  high 
degree  of  domestic  overcrowding  is  associated  with  a 


THE  CAUSATION   OF  TUBERCULOSIS  199 

low  and  declining  phthisis  death-rate  and  conversely 
that  a  persistently  high  phthisis  death-rate  may  occur 
with  a  less  but  still  diminishing  degree  of  overcrowd- 
ing? The  explanation  is  contained,  I  maintain,  in  the 
following  statement: 

A  given  amount  of  domestic  overcrowding  with  a 
large  amount  of  institutional  segregation  of  consump- 
tives is  associated  with  less  tuberculosis  than  when 
overcrowding  is  less  but  accompanied  by  only  a  small 
amount  of  institutional  segregation  of  consumptives. 
The  data  as  to  institutional  segregation  are  difficult 
to  obtain ;  but  there  is  sufficient  evidence  to  show  that 
in  countries  which  have  experienced  a  large  reduction 
in  the  death-rate  from  tuberculosis  a  large  proportion 
of  hospital  treatment  for  many  years  has  been  pro- 
vided for  consumptives,  while  in  countries  which  have 
not  experienced  this  decline  such  provision  has  been 
absent  or  imperfect.  In  London  about  56  per  cent., 
in  county  boroughs  35  per  cent.,  in  other  urban  dis- 
tricts 21  per  cent.,  and  even  in  rural  districts  of  Eng- 
land near  16  per  cent,  of  all  deaths  from  pulmonary 
tuberculosis  occur  in  hospitals  (poor-law  institutions, 
general  and  special  hospitals,  and  asylums).  Prior  to 
the  patient's  death  he  has  had  on  an  average  at  least 
three  months,  and  probably  in  the  aggregate  more 
nearly  five  or  six  months,  residential  treatment,  and 
this  at  the  stages  of  disease  in  which  there  is  the  great- 
est discharge  of  infective  material,  in  which  owing  to 


2OO  THE   CAUSATION    OF   TUBERCULOSIS 

feebleness  the  patient  is  least  able  to  control  its  hy- 
gienic disposal,  and  in  which — had  the  patient  been 
treated  at  home — the  relatives  would  'be  especially 
liable  to  receive  massive  infection,  and  would  be  en- 
feebled by  overwork  and  anxiety,  or  by  the  malnutri- 
tion associated  with  poverty. 

Some  writers  have  failed  to  visualize  the  fact  that 
the  segregation  of  a  minority  of  the  total  cases  of  pul- 
monary tuberculosis  for  a  portion  of  their  illness  can 
have  had  a  marked  influence  on  the  prevalence  of  this 
disease.  They  appear  to  be  judging  tuberculosis  by 
the  same  measure  as  they  would  apply  to  smallpox, 
which  in  an  unprotected  community  spreads  rapidly  if 
a  few  cases  are  overlooked.  The  case  of  tuberculosis, 
like  that  of  leprosy,  is  governed  by  the  considerations 
that  both  these  diseases  as  a  rule  require  intimate  and 
protracted  contact  for  their  spread,  and  that  in  both 
diseases  there  may  be  prolonged  latency  before  active 
disease  develops.  A  hypothetical  illustration  may  serve 
to  elucidate  the  order  of  magnitude  of  the  influence 
exercised  by  institutional  segregation.  Let  us  assume 
— as  is  probably  the  case  in  England — that  one-fifth  of 
the  cases  of  pulmonary  tuberculosis  are  treated  during 
one-third  of  a  year  institutionally  under  conditions  in 
which  they  will  not  be  liable  to  spread  infection.  Let 
us  assume  further  that  each  of  these  cases  has  an  in- 
fectious lifetime  of  three  years.  Thus  one-fifth  of  the 
cases  are  deprived  of  their  power  to  spread  infection 


THE   CAUSATION   OF  TUBERCULOSIS  2OI 

during  one-ninth  of  their  period  of  "open"  disease. 
It  being  assumed  that  personal  infection  causes  pul- 
monary tuberculosis  and  that  segregation  is  efficient, 
segregation  to  the  extent  indicated  above  should  se- 
cure a  reduction  in  the  death-rate  from  pulmonary 

100 
tuberculosis  of  — -    —  or  approximately  2  per  cent. 

5X9 
In  actual  fact  the  decline  in  the  English  death-rate 

from  pulmonary  tuberculosis  since  1871  has  been  at  a 
rate  slightly  under  2  per  cent,  per  annum. 

Koch's  Endorsement  of  Segregation  View 
An  extract  from  an  article  written  by  Robert  Koch 
shortly  before  his  death  may  be  permitted  (Epide- 
miologie  der  Tuberkulose  Zeitschr.  fur  Hyg.  und  In- 
f ektious  Krankheiten.  4.  XVII,  1910) . 

I  am  entirely  in  agreement  with  Newsholme  that  the  allo- 
cation of  consumptives  to  institutions  for  the  sick,  as  freely 
as  possible  and  for  as  long  as  possible,  is  the  most  active 
means  of  avoiding  infection  and  the  consequent  spread  of 
phthisis. 

In  my  experience,  too,  phthisis  has  shown  the  most  marked 
decline  in  those  places  where  comprehensive  measures  have 
been  taken  for  bringing  consumptives  into  hospitals,  and  the 
converse  has  been  the  case  where  the  converse  conditions 
prevail.  It  is  indeed  obvious  that  in  no  other  way  can  the 
danger  of  infection,  which  a  phthisical  patient  constitutes,  be 
so  effectively  removed  as  by  isolation  in  hospital.  Strong 
support  of  this  method  is  afforded  by  leprosy,  where  good 
results  in  attacking  the  disease  have  been  obtained  by  follow- 
ing the  same  principle. 

In  addition  t'o  this  factor  there  is  a  second,  which  also 
plays  a  very  important  part,  viz.,  housing. 


2O2  THE   CAUSATION   OF  TUBERCULOSIS 

A  hypothesis  explanatory  of  a  given  phenomenon 
should  be  consistent  with  all  the  associated  facts.  We 
have  seen  that  the  hypothesis  that  segregation  of  con- 
sumptives is  an  important  factor  in  the  reduction  of 
the  death-rate  from  pulmonary  tuberculosis  agrees  ( I ) 
with  our  knowledge  of  the  tubercle  bacillus,  and  (2) 
with  veterinary  and  agricultural  experience;  also  (3) 
that, — although  exact  data  are  unobtainable, — the  de- 
gree of  segregation  when  ascertainable  is  consistent 
with  the  degree  of  decline  in  the  death-rate;  (4)  it  is 
important  to  note  also  that  this  hypothesis  is  consistent 
with  the  otherwise  anomalous  facts  that  although  the 
proportion  of  the  population  subjected  to  urban  condi- 
tions of  life  has  steadily  increased,  and  the  number  of 
persons  per  inhabited  room  remains  much  greater  in 
towns  than  in  country  districts,  the  death-rate  from 
pulmonary  tuberculosis  in  England  has  declined  as 
much  in  them  as  in  country  districts ;  and  that  notwith- 
standing the  greater  overcrowding  in  towns,  the  urban 
is  rapidly  falling  to  the  level  of  the  rural  death-rate 
from  this  disease.  The  town  dweller's  better  and 
more  frequent  treatment  in  hospitals  is  an  important 
factor  in  overcoming  the  handicap  of  urban  conditions 
of  life,  including  overcrowding  and  preponderance  of 
indoor  and  dusty  occupations. 

It  is  desirable  to  supplement  the  above  statement  by 
some  remarks  on 


THE   CAUSATION   OF  TUBERCULOSIS  2O3 

Improved  Housing  as  a  Means  of  Reducing 

Tuberculosis 

Not  infrequently  the  thoughtless  remark  is  made 
that  given  improved  housing  sanatoria  and  hospitals 
for  consumptives  would  be  unnecessary.  The  fre- 
quent occurrence  of  tuberculosis  in  well-to-do  families 
shows  the  absurdity  of  this  statement.  It  is  true  that 
tuberculosis  is  more  prevalent  among  the  poor  living 
in  small  tenements  that  among  the  well-to-do;  but 
there  is  no  consistent  proportion  between  the  degree 
of  overcrowding  in  different  districts  or  towns  and 
the  death-rate  from  tuberculosis.  Improved  housing 
and  institutional  treatment  for  tuberculosis  cannot 
properly  be  regarded  as  alternatives.  They  are  nec- 
essary complements  to  each  other,  and  there  must  be 
increased  expenditure  in  both  directions,  if  tubercu- 
losis is  to  be  more  rapidly  reduced  in  amount.  There 
are  in  fact  two  housing  problems — for  the  healthy, 
and  for  the  sick.  The  most  rapid  method  of  improv- 
ing housing  for  the  healthy  is  to  remove  the  sick,  and 
especially  the  tuberculous  sick  to  a  hospital.  This  is 
being  done  year  by  year  to  an  increasing  extent.  In 
England  and  Wales  in  1870,  8.3  per  cent.,  and  in  1912 
21.6  per  cent,  of  all  deaths  from  all  causes  occurred  in 
public  institutions.  It  is  difficult  to  exaggerate  the 
practical  relief  implied  in  these  figures  in  respect  of 
satisfactory  housing,  especially  in  its  functional  aspect. 
Apart  altogether  from  the  tuberculosis  problem  much 


2O4  THE    CAUSATION    OF   TUBERCULOSIS 

of  the  decline  in  the  general  death-rate  must  be  attrib- 
uted to  the  skilled  treatment  which  a  large  proportion 
of  the  total  population  have  received  in  our  hospitals 
of  various  types. 

I  may,  I  think,  claim  to  have  answered  in  part  the 
question  asked  at  an  earlier  stage  of  this  address,  as 
to  the  causes  of  the  steady  decline  in  the  death-rate 
from  tuberculosis  in  recent  decades.  I  do  not  claim 
that  any  one  factor  has  brought  about  this  result.  I 
do  not  claim  that  it  has  been  caused  entirely  by  dimi- 
nution of  opportunities  of  infection;  but  I  deprecate 
the  view  that  improved  nutrition  and  other  conditions 
diminishing  susceptibility  have  played  a  predominant 
part.  The  facts  of  international  hygienic  history  re- 
but this  view.  Although  segregation  of  patients  in 
institutions  has  played  a  great  part  in  bringing  about 
the  result,  diminution  of  domestic  infection  as  the 
result  of  more  cleanly  habits  has  doubtless  had  an  im- 
portant influence ;  as  has  also  the  reduction  of  indus- 
trial dust. 

It  is  significant  that  general  hygiene  and  improved 
care  of  the  sick — quite  apart  from  any  intention  to 
segregate — were  associated  with  a  large  reduction  in 
the  death-rate  from  tuberculosis  before  the  importance 
of  reducing  infection  was  fully  appreciated;  and  that 
since  the  necessity  for  direct  measures  against  tuber- 
culosis was  realised,  since  such  measures  have  been 
begun,  however  imperfectly,  in  many  countries,  and 


THE   CAUSATION    OF   TUBERCULOSIS  2O5 

since  anti-tuberculosis  educational  propaganda  has 
been  somewhat  active,  there  has  been  no  increase 
in  the  rapidity  of  decline  of  the  death-toll  of  tuber- 
culosis. Of  course,  it  cannot  be  seriously — though 
it  is  foolishly — argued  from  this  fact  that  such  direct 
measures  are  futile.  Every  year  there  has  been  in- 
creasing migration  of  masses  of  people  into  towns, 
with  a  corresponding  increase  of  undesirable  domestic 
overcrowding  and  of  indoor  occupations.  If,  there- 
fore, such  anti-tuberculosis  measures  as  have  been 
adopted, — whether  direct  measures  or  general  sanitary 
measures, — had  been  associated  with  an  absence  of 
decline  or  with  actual  increase  in  the  death-rate  from 
tuberculosis  it  might  still  be  that  these  measures  have 
achieved  much.  Many  conflicting  agencies  are  at 
work,  and  it  might  well  be  that  the  apparent  lack  of 
success  of  the  measures  taken  is  due  to  the  increased 
operation  of  countervailing  influences.  The  impor- 
tance of  direct  action  for  the  control  of  tuberculosis 
must  be  judged  not  solely  by  necessarily  imperfect 
statistical  measurement  on  the  basis  of  a  few  years' 
observation,  but  by  ascertaining  that  the  proposed 
measures  are  in  accord  with  our  knowledge  of  the  nat- 
ural history  of  the  disease.  As  we  have  seen,  both 
comparative  and  human  pathology  assure  us  that  tu- 
berculosis is  a  communicable  and  therefore  a  preventi- 
ble  disease,  and  point  the  way  to  the  means  for  secur- 
ing this  end. 


206  THE  CAUSATION   OF  TUBERCULOSIS 

Before  describing  the  direct  measures  which  have 
been  adopted  for  the  control  of  tuberculosis,  it  should 
be  added  that  in  no  country  have  these  been  in  opera- 
tion sufficiently  long,  and  in  no  country  have  they  been 
so  adequately  applied,  as  to  render  it  practicable  to 
apply  statistical  measurement  -of  their  value;  mean- 
while these  measures  must  be  judged  in  the  light  of 
our  knowledge  of  the  pathology  of  tuberculosis. 

Notification  of  Tuberculosis 

If  every  tuberculous  patient  were  intelligent,  and 
willing  and  able  to  follow  the  advice  given  by  his  doc- 
tor, if  he  consulted  his  doctor  for  the  first  symptoms 
of  illness,  if  his  disease  were  recognized  by  the  doctor 
at  its  earliest  recognizable  stage,  and  if  the  doctor  in 
every  instance  gave  the  right  advice  and  made  the  nec- 
essary examinations  of  all  "  contacts,"  no  occasion 
would  arise  for  the  intervention  or  assistance  of  Pub- 
lic Health  Authorities,  except  in  providing  bacteriolog- 
ical facilities  and  institutional  accommodation.  In 
actual  fact  these  conditions  are  not  secured  for  the 
majority  of  patients;  and  the  private  practitioner, 
however  willing,  is  seldom  in  a  position  to  remedy  the 
domestic  and  industrial  insanitary  conditions  which 
favour  infection  and  lower  resistance  to  infection. 

Hence  notification  of  cases  of  tuberculosis  was  ad- 
vocated for  many  years  by  pioneer  medical  officers 
of  health  who  secured  voluntary  notification  by  doc- 


THE   CAUSATION   OF  TUBERCULOSIS  2O/ 

tors  of  a  considerable  proportion  of  the  total  cases  in 
their  districts,  and  in  a  few  instances  secured  compul- 
sory notification  by  local  enactment,  before  any  general 
regulations  on  the  subject  were  made.  It  is  note- 
worthy that  in  this  early  period  a  town  like  Brighton, 
which  had  voluntary  notification  with  sanatorium  pro- 
vision for  patients  willing  thus  to  be  treated,  secured 
the  notification  of  a  larger  proportion  of  total  cases 
than  another  town  in  which  notification  was  compul- 
sory, but  no  sanatorium  accommodation  had  been  pro- 
vided. The  point  is  mentioned  as  emphasizing  the 
general  principle  that  compulsory  measures  in  public 
health,  if  they  are  to  be  successful,  require  to  be  asso- 
ciated with  full  provision  for  the  action  which  should 
follow  the  compulsory  enactment ;  which  provision,  as 
in  this  case,  may  be  a  direct  inducement  to  compliance 
with  the  enactment.  In  view  of  the  change  of  central 
policy  involved  and  of  the  unpreparedness  of  most 
local  authorities  to  give  the  assistance  needed  for  noti- 
fied cases,  the  general  enforcement  of  notification  of 
tuberculosis  was  brought  about  in  stages;  in  1909 
poor-law  cases  of  consumption  were  made  notifiable 
throughout  England  and  Wales,  hospital  cases  in  1911, 
consumption  in  the  general  community  in  1912,  and  all 
forms  of  tuberculosis  in  1913. 

It  was  not  anticipated  that  complete  notification  of 
cases  would  be  obtained  for  some  years,  but  a  review  of 
English  national  experience  of  notification  of  tubercu- 


2O8  THE   CAUSATION    OF  TUBERCULOSIS 

losis  up  to  the  present  time  necessitates  the  confession 
that  there  has  been  failure  to  secure  the  cooperation 
of  an  unexpectedly  large  proportion  of  the  medical 
profession  in  this  public-health  duty.  Many  cases 
have  never  been  notified  and  in  a  large  number  of 
other  cases  notification  has  been  belated ;  Dr.  Barwise, 
County  Medical  Officer  of  Health  of  Derbyshire,  ob- 
tained information  as  to  417  deaths  certified  during 
1917  to  be  due  to  tuberculosis,  and  found  that  of  this 
number  39  per  cent,  had  never  been  notified,  and  that 
over  70  per  cent,  had  either  not  been  notified  or  died 
within  twelve  weeks  of  notification.  This  may  be  an 
exceptionally  bad  experience ;  but  the  duty  of  notifica- 
tion in  many  areas  is  only  imperfectly  performed,  and 
no  adequate  steps  are  being  taken  to  diminish  this 
default. 

As  notification  is  the  first  step  towards  coordinated 
measures  for  the  patient  and  in  the  interest  of  the 
public  health,  the  causes  of  .delay  in  notification  and 
of  failure  to  notify  deserve  further  examination. 

Causes  of  Failure  in  Notification 
I.  The  patient  himself  commonly  is  responsible  for 
much  delay  in  the  recognition  of  his  disease.  A  large 
proportion  of  consumptive  patients  refrain  from  ap- 
plying for  treatment  until  disease  is  fully  established, 
and  until  they  are  incapacitated  for  work.  Not  infre- 
quently this  means  that  the  patient  does  not  consult  a 


THE   CAUSATION   OF  TUBERCULOSIS  2O9 

doctor  until  a  few  months  or  even  weeks  before  his 
death.  Until  the  conditions  of  general  medical  prac- 
tice are  altered,  and  every  person  has  the  right  to  state- 
paid  medical  consultations,  belated  recourse  to  medical 
advice  will  continue. 

With  this  there  is  badly  needed  further  education  of 
the  public  as  to  seeking  advice  for  protracted  colds  and 
coughs,  or  for  other  symptoms  suggestive  of  tubercu- 
losis ;  and  a  wider  hygienic  propaganda  as  to  housing, 
overcrowding,  dusty  indoor  occupations,  expectora- 
tion, etc.,  is  also  called  for. 

2.  Under  present  conditions  of  medical  practice, 
early  diagnosis  of  tuberculosis  often  fails  to  be  se- 
cured, even  when  the  patient  places  himself  under 
medical  care.  It  is  to  the  private  practitioner  that 
most  patients  resort,  and  the  early  recognition  and 
treatment  of  disease  depends  primarily  (a)  on  his  skill, 
(&)  on  his  not  being  so  overworked  as  to  be  unable  to 
devote  adequate  time  to  the  examination  of  each  pa- 
tient coming  under  his  care,  and  (c)  on  his  willingness 
to  refer  doubtful  cases  for  consultation  with  the  offi- 
cial tuberculosis  officer  of  each  area.  These  officials 
have  only  existed  during  the  last  few  years;  their 
work  was  partially  in  abeyance  during  the  four  and  a 
half  years  of  war ;  and  apart  from  this,  they  have  not 
always  succeeded  in  persuading  the  private  practi- 
tioner that  their  cooperation  is  to  be  welcomed  and 
that  they  are  not  agents  for  depriving  him  of  his  pri- 
15 


2IO  THE    CAUSATION    OF   TUBERCULOSIS 

vate  patients.  This  assumed  antagonism  between  pri- 
vate and  public  medical  practice  is  one  of  the  most 
serious  difficulties  in  securing  more  rapid  progress  in 
anti-tuberculosis  work. 

3.  For  nearly  every  sanitary  area  gratuitous  facili- 
ties are  now  provided  for  the  examination  of  sputum 
for  tubercle  bacilli,  and  yet  in  many  areas  there  is 
grave  neglect  to  utilize  this  provision,  and  patients 
with   chronic   phthisis   may  be   treated   during  long 
months  or  even  years  for  "winter  cough,"  "bron- 
chitis," etc.,  without  adequate  physical  examination  of 
sputum.     The   diagnosis   of   pulmonary  tuberculosis 
ought,  it  is  true,  to  be  made  before  tubercle  bacilli  are 
found  in  the  sputum,  and  failure  to  recognize  the  dis- 
ease prior  to  this  implies  that  the  disease  has  already 
become  serious ;  but  in  fact  a  very  large  proportion  of 
consumptive  patients  for  many  months  have  tubercle 
bacilli  in  their  sputum,  before  the  diagnosis  of  tuber- 
culosis is  made. 

4.  When,  as  in  some  areas,  the  medical  officer  of 
health  or  the  tuberculosis  officer  takes  little,  if  any, 
useful  action  after  notifications  have  been  received,  the 
practitioner  has  an  excuse  for  not  notifying  subse- 
quent cases.     He  can  argue  with  some  cogency  that 
notification  has  no  value  per  se;  its  utility  depends  on 
the  action  which  follows  on  notification.     Unless  use- 
ful action  follows  on  notification,  default  in  notifica- 
tion has  little  practical  importance. 


THE  CAUSATION  OF  TUBERCULOSIS       211 

Public  Health  Action  Following  Notification 

Under  the  English  Tuberculosis  Regulations  -the 
medical  officer  of  health  or  an  officer  of  the  local  au- 
thority acting  under  his  instructions  is  required  to 
make  such  inquiries  and  take  such  steps  as  may  be 
necessary  or  desirable  for  investigating  the  source  of 
infection,  for  preventing  the  spread  of  infection,  and 
for  removing  conditions  favourable  to  infection.  The 
action  required  includes  inter  alia 

1.  Attention  to  the  personal  hygiene  of  the  patient, 
including  instruction  in  the  necessary  precautions  as 
to  coughing  and  expectoration. 

2.  Any  assistance  needed  to  ensure  for  the  patient 
(a)   Skilled  medical  attendance  and  nursing  as  re- 
quired while  he  is  treated  at  home ; 

(&)  Institutional  treatment  when  required; 

(c)  Supplementation  of  the  convalescent  patient's 
funds,  when  needed,  to  obviate  the  necessity  for  him 
at  once  to  embark  in  full-time  work ;  to  provide  addi- 
tional bedroom  accommodation  when  needed;  and  to 
ensure  that  the  patient  and  his  family  are  not  under- 
nourished or  overworked. 

3.  Remedial  action  for  any  insanitary  conditions  of 
the  home,  such  as  uncleanliness,  dampness,  overcrowd- 
ing ;  or  of  the  patient's  workplace,  especially  for  dusty 
occupations. 

4.  Examination  of  home  contacts  with  the  patient. 


212  THE    CAUSATION    OF   TUBERCULOSIS 

The  last  named  item  may  conveniently  be  consid- 
ered further  at  this  point. 

Examination  of  Contacts 

This  branch  of  tuberculosis  work  is  most  important. 
Often  the  first  notified  case  is  not  the  first  clinical  case 
of  tuberculosis  in  a  given  family ;  and  from  the  stand- 
point of  prevention  the  detection  of  such  cases  of 
longer  standing  is  important.  Examination  of  con- 
tacts also  frequently  discovers  patients  in  an  earlier 
and  more  curable  stage  of  disease  than  the  notified 
patient. 

It  is  important  that  all  home  contacts  of  each  noti- 
fied case  of  tuberculosis  should  be  examined ;  and  one 
of  the  most  important  functions  of  the  tuberculosis 
officer  is  to  arrange  for  this.  The  examination  may 
be  carried  out  by  arrangement  at  the  tuberculosis  dis- 
pensary; but  otherwise,  at  the  home  of  the  invaded 
family.  When  there  is  a  medical  practitioner  in  at- 
tendance his  cooperation  and  presence  should  as  a  rule 
be  invited. 

Such  systematic  examination  of  the  household  not 
only  is  more  efficient  in  discovering  sources  of  con- 
tinuing infection  than  the  desultory  examination  of  a 
few  contacts, — which  often  still  represents  the  extent 
of  this  important  work, — but  it  has  in  addition  a 
greater  educational  effect  on  the  public;  and  general 
recourse  to  such  systematic  observations  would  rap- 


THE   CAUSATION   OF   TUBERCULOSIS  213 

idly  improve  the  prospect  of  satisfactory  control  of 
tuberculosis. 

Even  when  examination  of  contacts  is  practised 
after  notification  of  a  case  of  pulmonary  tuberculosis, 
it  is  too  often  neglected  after  notification  of  non- 
pulmonary  cases.  This  represents  a  great  public- 
health  loss;  the  majority  of  cases  of  non-pulmonary 
tuberculosis  are  caused  by  infection  of  human  source, 
and  this  source  often  is  an  unrecognized  case  of  pul- 
monary tuberculosis  in  the  patient's  family. 

Scope  of  Tuberculosis  Schemes 
Prior  to  the  general  enforcement  of  notification  of 
tuberculosis  in  England  excellent  local  work  had  been 
done  in  a  relatively  small  number  of  areas  in  direct 
efforts  to  control  the  spread  of  tuberculosis,  in  addi- 
tion to  the  previous  general  measures,  such  as  im- 
proved sanitation,  better  housing,  more  satisfactory 
nutrition,  and  especially  the  hospital  treatment  of  a 
large  proportion  of  advanced  and  acute  cases  of  tuber- 
culosis. The  Report  of  the  last  Royal  Commission  on 
Tuberculosis  appeared  in  1911;  and  although  precau- 
tions against  human  infection  by  tuberculous  cows' 
milk  are  still  very  incomplete,  the  pasteurisation  or 
boiling  of  milk  is  more  generally  practised  than  in 
the  past. 

Local  Authorities  prior  to  1911  had  power  to  build 
sanatoria  or  otherwise  provide  institutional  accom- 


214       THE  CAUSATION  OF  TUBERCULOSIS 

modations  for  the  treatment  of  tuberculous  patients; 
relatively  little  had  been  done  in  most  areas.  In  191 1 
the  Finance  Act  provided  a  sum  of  £1,116,000  for  the 
erection  of  sanatoria  in  England  and  Wales,  and  this, 
with  money  provided  by  local  rates,  has  led  to  rapid 
increase  in  accommodation  for  the  residential  institu- 
tional treatment  of  tuberculosis.  In  England  in  1911 
local  authorities,  other  than  poor-law  authorities,  had 
about  1300  beds  for  the  institutional  treatment  of  tu- 
berculosis, while  there  were  4,200  beds  in  private  sana- 
toria and  voluntary  institutions.  In  191 7. the  total 
available  beds  numbered  12,441,  of  which  about  one- 
half  had  been  provided  by  local  authorities. 

In  1911  the  National  Insurance  Act  was  passed  and 
came  into  operation  in  July,  1912.  This  provided  a 
special  "  Sanatorium  Benefit." 

The  Departmental  Committee  appointed  to  make 
recommendations  as  to  detailed  direct  measures  against 
tuberculosis,  reported  in  April,  1912,  that  any  scheme 
which  is  to  form  the  basis  of  an  attempt  to  deal  with 
the  problem  of  tuberculosis  should  be  available  for  the 
whole  community,  and  that  its  organization  should  be 
undertaken  by  the  large  local  authorities  (the  councils 
of  counties  and  county  boroughs).  These  recommen- 
dations were  at  once  adopted  by  the  Government, 
which  undertook  to  provide  out  of  the  national  ex- 
chequer one-half  of  the  net  cost  of  approved  local 
schemes  for  the  general  treatment  of  tuberculosis. 


THE   CAUSATION   OF  TUBERCULOSIS  215 

Local  authorities  were  invited  at  once  to  prepare 
schemes  for  institutional  treatment,  residential  and 
non-residential,  domiciliary  treatment  remaining  in  the 
hands  of  private  practitioners,  of  poor-law  doctors, 
and  of  doctors  engaged  in  the  contract  work  under  the 
National  Insurance  Act  ("panel  doctors").  The 
last  named  are  in  medical  charge  of  the  large  mass  of 
the  wage-earners  of  the  community,  comprising  roughly 
one-third  of  the  total  population,  in  so  far  as  their 
treatment  at  home  is  within  the  power  of  a  practi- 
tioner of  average  competence.  The  schemes  proposed 
for  each  area  comprised, 

1.  The  appointment  of  a  tuberculosis  officer,  usually 
a  whole-time  official,  who  was  required  to  have  had 
special  experience  in  the  diagnosis  and  treatment  of 
tuberculosis,  and  who  as  a  rule  was  an  officer  in  the 
public-health  department  under  the  administrative  su- 
pervision of  the  medical  officer  of  health,  but  inde- 
pendent in  his  clinical  work ; 

2.  The  establishment  of  tuberculosis  dispensaries,  at 
which  patients  were  treated,  consultations  as  to  doubt- 
ful cases  held,  and  contacts  examined; 

3.  The  provision  of  beds  in  residential  institutions 
for  curable  and  for  acute  and  advanced  cases; 

4.  The  organization  of  arrangements  for  "  follow- 
ing up  "  and  "  after-care." 

During  1912  and  1913  advance  was  made  in  these 
directions.     In    1911    there  were  25-30  tuberculosis 


216  THE   CAUSATION   OF  TUBERCULOSIS 

dispensaries:  in  1917  their  number  had  increased  to 
371.  In  1914  the  onset  of  the  Great  War  prevented 
further  development  of  tuberculosis  work  and  se- 
riously crippled  and  reduced  the  efficiency  of  work 
already  initiated;  and  this  increased  as  the  military 
demand  for  medical  officers  and  institutions  became 
greater.  It  may  be  stated  generally  that  in  only  a 
relatively  small  number  of  areas  have  fairly  complete 
arrangements  for  the  institutional  treatment  of  tuber- 
culosis come  into  operation;  and  that  even  in  these 
areas  the  arrangements  have  been  at  work  for  only  a 
limited  period.  It  is  evident,  therefore,  as  already 
pointed  out,  that  no  argument  as  to  the  utility  of  these 
arrangements  can  be  based  on  the  facts  that  the  death- 
rate  from  tuberculosis  has  not  declined  with  increased 
rapidity  in  recent  years,  and  that  women  during  the 
war,  especially  at  the  working  years  of  life  have  expe- 
rienced an  increased  death-rate  from  this  disease. 

Tuberculosis  Dispensaries 

The  tuberculosis  officer  is  the  essential  element  in 
the  dispensary;  and  in  rural  districts  he  may  be  said 
to  carry  the  dispensary  under  his  hat.  The  dispen- 
sary if  properly  organized  should  serve  as  the  centre 
of  official  anti-tuberculosis  measures.  The  medical 
officer  of  health  receives  the  notifications  of  recog- 
nised cases  whether  they  are  attending  the  dispensary 
or  not ;  and  it  simplifies  administration  if  the  home  su- 


THE   CAUSATION    OF   TUBERCULOSIS  217 

pervision  of  all  tuberculous  patients  notified  to  the 
medical  officer  of  health,  and  not  only  of  dispensary 
patients,  is  placed  under  the  supervision  of  the  tuber- 
culosis officer.  At  the  dispensary  itself  the  tubercu- 
losis officer  examines  patients,  makes  records  of  their 
condition,  and  of  all  facts  bearing  on  their  welfare, 
and  recommends  the  special  form  of  continued  treat- 
ment adapted  to  their  condition.  This  may  be  domi- 
ciliary, or  given  at  the  dispensary,  or  in  a  sanatorium, 
or  in  a  hospital.  A  dispensary  which  does  not  super- 
vise and  treat  a  large  proportion  of  the  total  notified 
cases,  including  especially  patients  before  and  after 
they  have  received  treatment  in  a  residential  institu- 
tion, is  not  fulfilling  its  possibilities  of  utility. 

At  the  dispensary  is  organized  also  the  examination 
by  the  tuberculosis  officer  of  "  contacts,"  and  of  school 
children  suspected  to  be  tuberculous;  though  it  is 
often  necessary  to  arrange  for  this  officer  to  make 
similar  examinations  at  patients'  homes.  At  the  dis- 
pensary consultations  with  private  practitioners  are 
conveniently  held;  though  in  this  instance  also  the 
tuberculosis  officer  should  arrange  when  this  is  desired 
for  the  consultations  to  be  held  at  the  patient's  home. 

The  dispensary  alone  cannot  ensure  the  welfare  of 
the  tuberculous  patient.  It  is  necessary  that  the  tuber- 
culosis officer  should  have  consultations  concerning 
difficult  cases  with  the  medical  staff  of  general  and 
special  hospitals.  To  segregate  the  treatment  of  tu- 


2l8  THE   CAUSATION   OF  TUBERCULOSIS 

berculosis  from  that  of  other  diseases  means  reduced 
efficiency  of  the  tuberculosis  officers  and  lowered  qual- 
ity of  treatment. 

Tuberculosis  Dispensaries  should  become  Parts  of 
General  Dispensaries 

Public  Health  and  School  Authorities  have  already 
established  many  centres  at  which  hygienic  instruc- 
tions and  medical  treatment  are  given  for  mothers  and 
their  young  children  when  ailing,  or  with  a  view  to  the 
prevention  of  future  illness;  for  tuberculosis;  for 
venereal  diseases;  and  for  various  ailments  of  school 
children. 

In  England  in  addition  there  is  poor-law  provision 
(sometimes  at  dispensaries)  for  patients  dependent  on 
official  charity.  Evidently  the  multiplicity  of  authori- 
ties, local  and  central,  concerned  in  this  medical  work, 
is  not  conducive  to  efficiency;  and  it  will,  we  hope, 
soon  disappear.  Similarly  it  will  be  in  the  interest  of 
efficiency,  as  well  as  of  economy,  to  provide  for  the 
treatment  of  the  above-named  groups  of  cases  in  a 
common  Medical  Institute  for  each  defined  area,  at 
which  also  it  will  be  advantageous  to  arrange  for  much 
of  the  treatment  of  insured  persons.  By  this  means  it 
will  become  practicable  to  arrange  for  consultations 
between  experts  in  different  departments  of  medicine, 
to  the  advantage  of  all  concerned. 

It  will  be  contrary  to  the  communal  interest  if  the 


THE    CAUSATION    OF   TUBERCULOSIS  2IQ 

resources  of  voluntary  hospitals  in  large  towns  are  not 
also  utilised  in  official  medical  work.  Many  of  these 
hospitals  have  specialised  departments  (e.g.,  X-ray, 
eye,  ear,  throat,  skin,  and  other  special  clinics),  the 
use  of  which  ought  to  be  obtainable,  even  though  for 
many  years  it  may  not  be  practicable  to  arrange  for  all 
hospitals  to  be  financed  in  part  at  least  out  of  rates 
and  taxes. 

The  tuberculosis  officer  in  order  to  be  able  to  treat 
his  dispensary  patients  with  adequate  knowledge,  and 
in  order  to  advise  as  to  the  form  of  treatment — in  a 
residential  institution  or  not, — most  fitted  to  the  pa- 
tient's case,  must  know  the  sanitary  and  social  circum- 
stances of  the  patient's  industrial  and  domiciliary  life. 
He  must,  therefore,  have  reports  on  these  circum- 
stances respecting  each  patient.  This  raises  the  gen- 
eral question  of  the  relation  of  the  tuberculosis  officer 
to  the  medical  officer  of  health.  The  medical  officer 
of  health  is  officially  responsible  for  controlling  the 
tuberculous  patient  and  his  environment  from  a  public 
health  standpoint.  As  the  tuberculosis  officer  also 
needs  the  information  acquired  in  the  inquiries  which 
it  is  the  duty  of  the  medical  officer  of  health  to  make 
personally  or  by  an  authorized  agent,  coordination  of 
the  work  of  the  two  officers  is  evidently  required; 
and  this  need  cause  no  difficulty  when  the  tuberculosis 
officer  is  an  officer  in  the  Public  Health  Department  of 
which  the  medical  officer  of  health  is  the  chief  admin- 
istrator. 


22O  THE   CAUSATION   OF   TUBERCULOSIS 

The  Home  Visitation  of  Patients 

This  is  important,  (a)  to  inquire  into  the  social  cir- 
cumstances of  each  patient;  (&)  to  instruct  him  in 
detail  as  to  the  carrying  out  of  instructions  for  treat- 
ment and  in  the  hygiene  of  his  life;  (c)  to  make  a 
sanitary  survey  of  the  dwelling  house,  and  especially 
of  the  patient's  bedroom,  and  to  advise  as  to  any 
needed  reforms;  and  (d)  in  certain  cases  to  give  act- 
ual assistance  in  nursing  the  patient. 

The  report  on  these  inquiries  should  be  seen  by  both 
the  medical  officer  of  health  and  the  tuberculosis  offi- 
cer, and  on  them  in  conjunction  with  the  tuberculosis 
officer's  knowledge  of  the  medical  condition  of  the 
patient,  the  subsequent  course  of  supervision  and 
treatment  will  depend. 

Home  visitation  can  be  carried  out  by  nurses  at- 
tached to  the  dispensary  or  by  inspectors  of  the  public 
health  department.  The  latter  will  usually  be  more 
competent  in  detecting  and  remedying  sanitary  defects 
in  the  home ;  the  former  in  encouraging  the  patient  to 
carry  out  the  needed  requirements  in  personal  hygiene 
and  nursing.  Many  visitors  are  equally  competent  in 
both  directions ;  and  as  the  number  of  women  specially 
trained  in  tuberculosis  work  increases  this  will  more 
generally  be  the  rule. 

The  dispensary  should  be  the  active  working  centre 
from  which  home  visitation  is  undertaken ;  and  this  is 
especially  important  in  "  following  up "'  work.  Fol- 


THE    CAUSATION   OF   TUBERCULOSIS  221 

lowing  up  is  needed  for  persons  who  have  been  exam- 
ined once,  concerning  whom  there  is  doubt  as  to  their 
freedom  from  disease  and  who  fail  to  present  them- 
selves for  later  examination.  It  is  needed  also  for 
patients  who  have  been  under  treatment  and  neglect 
to  continue  it ;  and  for  patients  who  after  having  been 
treated  have  been  discharged  and  fail  to  report  them- 
selves at  intervals  as  directed.  It  is  important  to  have 
efficient  arrangements  for  ascertaining  these  leakages 
and  for  making  the  necessary  inquiries.  The  method 
of  securing  this  will  vary  according  to  local  circum- 
stances ;  but  the  following  example  given  by  Dr.  Chap- 
man of  an  official  method  may  be  placed  on  record : 

When  a  patient  is  instructed  to  attend  again  at  the  dispen- 
sary his  name  is  noted  in  a  diary  under  the  date  upon  which 
he  is  asked  to  attend.  In  some  instances  a  definite  time  is 
fixed  for  the  appointment  so  as  to  save  the  patient's  time. 
The  names  of  all  patients  who  attended  the  dispensary  upon 
the  day  appointed  are  ticked  off  as  they  are  seen,  and  at  the 
end  of  the  day  the  names  of  patients  who  have  failed  to 
attend  remain  on  the  list.  Letters  are  then  sent  reminding 
these  patient's  of  their  engagement  and  making  another  ap- 
pointment. If  they  still  fail  to  attend  they  are  visited  by  the 
dispensary  nurse  or  the  health  visitor.  Failure  to  attend  may 
be  due  t'o  relapse,  and,  when  this  is  likely,  an  early  visit  of 
inquiry  by  the  nurse  is  advantageous. 

Examination  of  a  register  kept  for  faciliating  work  of  this 
kind  showed  that  the  majority  of  the  patients  followed  up 
attended  subsequently,  and  that  in  the  cases  of  the  remainder 
non-attendance  as  a  rule  was  satisfactorily  explained. 

In  areas  having,  as  yet,  no  adequate  system  of  fol- 


222  THE   CAUSATION   OF   TUBERCULOSIS 

lowing  up,  an  appreciable  percentage  of  patients  usu- 
ally cease  to  attend  during  the  course  of  treatment  at 
a  dispensary,  and  many  are  lost  sight  of  after  dis- 
charge from  a  sanatorium.  The  value  of  the  work  of 
a  dispensary  and  of  after-care  work  is  materially  im- 
paired in  the  absence  of  a  system  of  "  following  up." 
As  schemes  develop,  more  stress  will  doubtless  be 
generally  laid  upon  this  branch  of  the  dispensary 
function. 

"  Sanatorium  Benefit." 

Under  the  National  Insurance  Act  the  annual  sum 
of  is  3d  (30  cents)  was  set  apart  for  each  insured 
person;  as  the  result  of  subsequent  bargaining  with 
medical  practitioners  6d  of  this  was  devoted  to  the 
domiciliary  treatment  of  tuberculosis  patients  (payable 
on  the  number  of  panel  patients  on  each  doctor's  list, 
not  on  the  number  of  his  tuberculous  patients),  the 
remainder  being  payable  to  local  authorities  who  un- 
dertook the  provision  of  institutions  for  the  treatment 
of  tuberculous  insured  patients. 

Thus  the  "  Sanatorium  Benefit "  comprises 

A.  Domiciliary  treatment. 

B.  Institutional  treatment. 

(a)  Non-residential — Dispensaries. 

(6)  Residential — Sanatoria, 
Hospitals, 

Convalescent  Homes  and 
"  Farm  Colonies." 


THE   CAUSATION   OF  TUBERCULOSIS  223 

Soon  after  the  passing  of  the  National  Insurance 
Act  in  1911  representations  were  made  that  tubercu- 
losis affected  non-insured  as  well  as  insured;  that 
treatment  of  insured  could  have  only  partial  success 
so  long  as  non-insured  members  of  the  same  house- 
hold were  neglected ;  and  that  this  was  work  for  public 
health  authorities  which  they  were  already  partially 
undertaking.  It  was  evident  that  the  inextricably  in- 
terlaced measures  for  the  prevention  and  the  treat- 
ment of  tuberculosis  must  accrue  to  the  whole  popu- 
lation ;  and  the  mistake  of  the  National  Insurance  Act 
was  remedied  to  the  extent  that  Public  Health  Au- 
thorities were  informed  that  the  National  Treasury 
was  prepared  to  pay  one-half  of  the  approved  expen- 
diture incurred  by  these  authorities  in  establishing 
schemes  for  the  treatment  of  tuberculosis  available  for 
the  entire  population.  Such  schemes  were  proceeded 
with,  as  already  indicated ;  but  there  remained  the  fact 
that  insured  persons  who  had  paid  their  weekly  quota 
and  were  therefore  entitled  to  "  Sanatorium  Benefit " 
usually  interpreted  this  as  a  right  to  three  months' 
treatment  in  a  Sanatorium.  The  choice  of  persons  to 
receive  treatment  in  a  Sanatorium  lay  with  Local 
Insurance  Committees  appointed  under  the  National 
Insurance  Act,  who  generally  acted  on  the  advice  of 
the  tuberculosis  officer ;  but  influences  other  than  med- 
ical led  to  the  unsatisfactory  use  of  institutional  treat- 
ment. A  large  number  of  patients  were  sent  to  and 


224  THE   CAUSATION    OF   TUBERCULOSIS 

retained  in  sanatoria  for  prolonged  periods,  who 
might  have  been  adequately  treated  at  home,  or  who 
should  have  been  in  hospitals.  Satisfactory  results 
for  sanatorium  treatment  were  not  secured  under 
these  conditions ;  and  there  will  probably  be  no  mate- 
rial improvement  until  the  Sanatorium  Benefit  is  with- 
drawn as  a  special  benefit  under  the  National  Insur- 
ance Act,  and  the  treatment  of  tuberculosis  becomes 
an  obligatory  duty  of  Public  Health  Authorities,  with 
a  minimum  standard  of  provision  to  which  all  must 
attain. 

Residential  Institutions 

The  extent  to  which  these  have  been  provided  in 
England  since  1911  has  already  been  stated.  The 
number  of  beds  available  in  1917  was  12,441,  in  addi- 
tion to  some  9,000  beds  in  poor-law  institutions,  which 
in  1911  were  occupied  by  consumptives.  From  the 
point  of  view  of  the  provision  required  in  residential 
institutions  for  the  treatment  of  tuberculosis  the  fol- 
lowing classification  is  useful.  It  is  confined  to  pul- 
monary cases : 

Group  A — Cases  in  which  permanent  improvement  or 
recovery  can  usually  be  anticipated. 

Group  B — Cases  in  which  only  temporary,   though 
possibly  prolonged,  improvement  may  be 
anticipated. 
This  group  will  include 


THE   CAUSATION   OF  TUBERCULOSIS  225 

1.  Patients  who  may  be  expected  to  recover  consid- 

erable ability  to  work,  as  a  result  of  protracted 
treatment. 

2.  Patients  admitted  for  a  short  term  for  educational 

treatment. 

3.  Patients  with  advanced  disease,  many  of  whom  im- 

prove greatly  under  institutional  treatment. 
Group  C — Advanced  cases  requiring  continuous  med- 
ical care  and  nursing. 
Group  D — Cases  requiring  Special  Observation. 

1.  Patients  admitted  for  the  purpose  of  diagnosis. 

2.  Patients  needing  to  be  watched,  before  the  best  form 

of  continued  treatment  can  be  determined. 
Emergency  cases,  e.g.,  patients  with  haemoptysis,  and 
patients  requiring  surgical  treatment  may  come 
within  any  of  the  above  groups. 

Of  the  12,441  beds  probably  5,000  are  in  the  hands 
of  voluntary  organizations,  and  are  intended  for  pa- 
tients in  group  A,  though  for  the  reasons  set  out  on 
pages  208  and  223  they  contain  a  large  proportion  of 
patients  in  the  other  groups.  It  appears  not  unlikely, 
however,  that  the  total  accommodation,  official  and 
voluntary,  for  patients  in  group  A  has  reached  one  bed 
per  5,000  population,  the  accommodation  recommended 
by  the  Departmental  Committee  on  Tuberculosis  as 
immediately  advisable.  This  accommodation  is  un- 
evenly distributed  and  much  of  it  is  being  utilised  for 
16 


226  THE   CAUSATION    OF   TUBERCULOSIS 

patients  coming  within  groups  B,  C,  and  D.  All  the 
evidence  available  shows  a  great  need  for  additional 
beds  for  patients  coming  within  the  last-named  groups. 
The  Departmental  Committee  recommended  that  the 
total  needs  of  the  community  might  be  assumed  to 
amount  to  one  bed  to  2,500  population  for  all  stages 
of  pulmonary  tuberculosis,  in  addition  to  poor-law  ac- 
commodation. This  means  a  provision  of  some  14,000 
beds  in  addition  to  the  9,000  poor-law  beds,  or  a  total 
provision  of  about  one  bed  to  1,500  population. 

If  we  include  cases  of  non-pulmonary  tuberculosis 
it  may  be  safely  assumed  that  each  community  should 
aim  at  having  available  for  the  treatment  of  tubercu- 
losis at  least  one  bed  per  1,000  inhabitants.  Fewer 
beds  may  suffice  for  sparsely  populated  communities, 
and  more  will  be  needed  in  some  towns. 

In  England  various  existing  institutions  have  been 
utilised  in  the  treatment  of  tuberculosis. 

i.  Emphasis  has  already  been  laid  on  the  large  num- 
ber of  beds  in  workhouse  infirmaries  under  the  Poor- 
Law  Authorities.  Of  the  historical,  as  well  as  of  the 
present  value  of  this  accommodation  for  advanced 
cases  of  tuberculosis  in  the  poorest  section  of  the  popu- 
lation— which  is  most  seriously  exposed  domestically 
to  massive  infection, — there  can  be  no  doubt. 

But  there  has  been  prejudice  against  the  use  of 
this  accommodation  for  insured  persons,  and  such  use 
is  legally  precluded ;  and  since  the  passing  of  the  Na- 


THE   CAUSATION   OF  TUBERCULOSIS  227 

tional  Insurance  Act  additional'  provision  has  been 
made  by  Public  Health  Authorities,  and  ere  long  the 
whole  of  the  present  poor-law  accommodation  should 
come  under  public  health  authorities. 

2.  Detached  pavilions  of  hospitals  for  infectious  dis- 
eases have  also  been  employed  for  the  treatment  of 
tuberculosis,  and  experience  has  demonstrated  that  in 
well-conducted  institutions  consumptives  are  not  ex- 
posed to  risk  of  acquiring  acute  infectious  diseases. 

The  use  of  these  institutions  favours  economy  of 
administration.  It  possesses  the  advantage  that  pa- 
tients are,  as  a  rule,  more  accessible  to  their  relatives 
than  in  a  sanatorium;  and  this  renders  patients  suf- 
fering from  progressive  disease  more  willing  to  remain 
in  the  institution  than  they  would  otherwise  be.  Pa- 
tients can  advantageously  be  placed  in  such  an  insti- 
tution for  observation,  before  deciding  whether  pro- 
longed treatment  in  a  distant  curative  sanatorium  is 
indicated. 

Occasionally  empty  smallpox  hospitals  have  also 
been  employed  for  the  institutional  treatment  of  tuber- 
culosis ;  but  if  this  plan  were  to  be  generally  adopted, 
tuberculosis  work  would  be  seriously  crippled  if  small- 
pox became  epidemic.  The  treatment  of  consumptives 
in  a  smallpox  hospital  should  only  be  permitted  for 
patients  who  could  be  at  once  transferred  and  who  can 
be  at  once  vaccinated. 

General  hospitals  are  well  fitted  to  deal  with  the  fol- 
lowing classes  of  cases  of  tuberculosis : 


228  THE   CAUSATION   OF  TUBERCULOSIS 

(a)  Patients  admitted  for  observation,  with  a  view  to 
diagnosis ; 

(&)  Patients  admitted  to  ascertain  the  form  of  treat- 
ment best  adapted  for  the  patient's  needs ; 

(c)  Emergency  cases,  e.g.,  haemoptysis; 

(</)  Patients  requiring  surgical  aid  for  intercurrent 
diseases ; 

(e)  Patients  with  advanced  disease  admitted  for  spe- 
cial purposes; 

(/)  Patients  with  non-pulmonary  tuberculosis,  requir- 
ing special  surgical  treatment. 

In  approving  arrangements  for  the  treatment  of 
pulmonary  tuberculosis  in  a  general  hospital,  it  should 
be  made  a  condition  that  they  shall  not  be  received  into 
general  wards  of  the  hospital  in  which  there  are  per- 
sons suffering  from  other  diseases,  unless  for  a  sudden 
emergency,  or  for  a  short  period  for  operative  treat- 
ment, or  unless  there  is  no  expectoration,  or  if  this,  on 
repeated  examinations  has  been  found  to  be  free  from 
tubercle  bacilli. 

Sanatoria  and  Combined  Institutions 
To  ensure  efficiency  in  a  santorium  a  resident  physi- 
cian is,  as  a  rule,  necessary;  and  this  is  desirable  also 
for  a  tuberculosis  hospital.  Smaller  authorities  may 
be  unable  to  combine  together  or  to  provide  alone  an 
institution  with  about  100  beds,  which  is  generally  re- 
garded as  the  unit  best  adapted  to  secure  a  well-placed 


THE   CAUSATION   OF  TUBERCULOSIS 

and  efficiently  organized  institution,  with  due  regard 
to  economy  of  administration.  To  provide  such  a 
unit,  and  even  apart  from  this,  the  desirability  of  treat- 
ing patients  in  all  stages  of  disease  in  the  same  insti- 
tution should  be  considered.  Experience  in  England 
has  shown  that  this  combination  presents  no  medical 
administrative  difficulties,  provided  that  the  type  of 
sleeping  accommodation  for  patients  consists  chiefly 
of  rooms  for  one  or  two  patients  or  of  small  wards. 
With  such  an  arrangement,  if  a  section  of  the  institu- 
tion consisting  of  one  or  two  bedded  rooms  or  small 
wards  is  devoted  to  patients  needing  special  nursing, 
irrespective  of  the  stage  of  disease,  efficiency  is  se- 
cured, the  special  needs  of  each  class  of  patients  can 
be  met,  and — this  is  especially  important — the  patient 
with  advanced  disease  cannot  infer  the  hopeless  char- 
acter of  his  illness  from  his  place  in  the  institution. 
Such  a  combined  institution  affords  the  medical  and 
administrative  advantage  that  the  tuberculosis  officer 
can,  as  a  rule,  watch  his  patients  throughout  the  whole 
course  of  their  treatment,  both  in  the  residential  insti- 
tution and  at  the  dispensary. 

In  choosing  a  sanatorium  an  area  of  at  least  twenty 
acres  should  be  available;  and  at  least  one-fifth  of  an 
acre  should  be  allowed  per  patient.  For  a  hospital  a 
smaller  area  is  permissible.  There  should  be  a  floor- 
space  of  at  least  64  square  feet  for  each  patient ;  and 
the  centres  of  the  heads  of  adjacent  beds  should  not 


THE    CAUSATION   OF   TUBERCULOSIS 

be  distant  less  than  8  feet  measured  against  the  wall. 
Experience  appears  to  show  that  in  a  large  sanatorium 
one  nurse  will  generally  be  adequate  for  every  twelve 
patients.  In  a  hospital  for  advanced  patients,  or  in  a 
combined  institution  a  larger  staff  may  be  required. 

Observation  Beds 

There  is  but  little  systematised  experience  as  yet  of 
the  employment  of  observation  beds ;  a  difficulty  aris- 
ing from  the  fact  that  the  tuberculosis  officer  under 
most  local  tuberculosis  schemes  has  not  been  suffi- 
ciently in  touch  with  the  medical  officers  of  the  resi- 
dential institutions  to  which  he  sends  patients.  There 
are  practical  difficulties  in  the  provision  of  observa- 
tion beds  on 'the  dispensary  premises,  including  the 
difficulty  of  due  regard  to  economy  of  administration 
in  the  nursing  and  treatment  of  three  or  four  in- 
patients  at  a  dispensary.  Whatever  arrangements  are 
made  for  such  beds,  it  is  desirable  that  the  tuberculosis 
officer  should  have  access  to  the  patients  treated  in 
them. 

General  Observations  on  Treatment  in  Sanatoria 
In  1911  the  extent  and  limitations  of  the  utility  of 
sanatorium  treatment  of  tuberculosis  were  already 
fairly  well  recognized  by  physicians;  and  it  is  unfor- 
tunate that  in  connection  with  the  passage  of  the  Na- 
tional Insurance  Act  this  treatment  acquired  a  some- 


THE   CAUSATION   OF  TUBERCULOSIS  23! 

what  political  aspect,  and  became  the  subject  of  much 
popular  misapprehension  and  exaggeration.  Disap- 
pointment necessarily  followed  on  the  sending  of 
patients  to  sanatoria  for  treatment  with  a  view  to  cure 
at  a  stage  of  disease  when  anything  beyond  ephemeral 
improvement  was  impossible.  The  patients  who,  un- 
der present  conditions,  are  admitted  to  sanatoria  come 
roughly  into  two  groups : 

First.  Patients  with  limited  disease  and  little  or  no 
systemic  disturbance.  Comparatively  few  patients  who 
now  enter  sanatoria  come  within  this  group. 

Second.  Patients  with  more  extensive  or  acute  dis- 
ease. In  a  large  proportion  of  cases  within  the  first 
group  the  immediate  result  of  sanatorium  treatment 
extending  over  three  to  six  months  is  the  complete 
restoration  of  general  health  and  working  capacity 
with  arrest  of  disease.  In  a  large  further  proportion 
of  cases  in  the  same  group  there  is  recovery  of  work- 
ing capacity  and  apparent  restoration  of  general  health 
without  complete  arrest  of  disease. 

For  patients  coming  within  the  second  group  a  simi- 
lar period  of  treatment  in  a  sanatorium  results : 

(a)  In  restoration  of  general  health  and  working 
capacity  with  arrest  of  disease  in  only  a  small  propor- 
tion of  cases ; 

(&)  In  recovery  of  working  capacity  and  apparent 
restoration  of  general  health  without  arrest  of  disease 
in  a  fair  proportion  of  cases ;  and 


232  THE   CAUSATION   OF  TUBERCULOSIS 

(c)  In  the  remainder,  disease  progresses  steadily 
with  or  without  temporary  improvement  in  general 
health. 

The  subsequent  history  of  sanatorium  patients  varies 
greatly.  Some  of  them  maintain  their  health  indefi- 
nitely on  return  to  their  ordinary  life.  Others  who 
have  been  discharged  with  arrested  disease  ultimately 
relapse,  even  if  they  live  under  excellent  environmental 
conditions;  and  such  relapses  are  excessive  among 
those  who  return  to  unsatisfactory  conditions  of  life 
and  work. 

Among  patients  discharged  from  a  sanatorium  with- 
out arrest  of  the  disease  a  small  proportion  ultimately 
recover  completely,  but  the  majority  relapse  at  a  date 
which  is  earlier  or  later  in  accordance  more  or  less 
with  the  conditions  under  which  they  live  and  work 
and  the  severity  of  their  disease. 

The  experience  of  the  last  few  years  has  been  that 
only  a  small  proportion  of  the  patients  admitted  to 
sanatoria  are  cases  in  which  arrest  of  the  disease  can 
be  anticipated ;  and  this  will  continue  until  the  disease 
is  more  generally  detected  at  an  earlier  stage  than  at 
present,  and  the  sanatorium  treatment  is  prescribed 
and  continued  solely  in  accord  with  the  medical  needs 
of  the  patient. 

The  conditions  of  local  administration  of  the  Sana- 
torium Benefit  under  the  National  Insurance  Act  have 
led  to  a  very  high  proportion  of  consumptives  being 


THE   CAUSATION   OF  TUBERCULOSIS  233 

treated  in  sanatoria  with  a  view  to  cure,  who  might 
advantageously  have  received  educational  treatment 
for  a  few  weeks  and  then  have  been  treated  at  home 
or  at  a  tuberculosis  dispensary.  Furthermore,  a  large 
number  of  patients  with  advanced  disease  have  been 
sent  to  sanatoria  for  whom  treatment  in  a  hospital  was 
more  appropriate. 

Educational  Work  of  Sanatoria 
Apart  from  the  question  of  cure,  which  with  belated 
treatment  can  only  be  expected  in  a  minority  of  cases, 
the  sanatorium  serves  an  important  purpose,  not  only 
in  restoring  patients  to  a  considerable  degree  of  health 
and  working  capacity  for  a  longer  or  shorter  time,  but 
also  in  educating  the  patients  how  to  live  and  conduct 
themselves.  A  stay  in  a  sanatorium  for  a  short  period 
— a  month  or  six  weeks — under  doctors  and  nurses 
who  realise  the  value  of  this  work — would  there  were 
more  of  these ! — secures  the  training  of  the  patient  on 
lines  beneficial  to  his  future  health  and  enables  him  to 
obviate  all  danger  for  others. 

In  such  a  short  stay  in  a  sanatorium  what  may  be 
called  tuberculosis  discipline  can  be  and  is  acquired 
when  the  sanatorium  is  satisfactorily  administered; 
and  the  patient  thus  disciplined  is  in  a  much  more 
favorable  position  for  securing  his  own  welfare  and 
that  of  others  than  the  undisciplined  patient,  just  as 
the  soldier  who  has  had  routine  drill  under  a  compe- 


234  THE   CAUSATION    OF   TUBERCULOSIS 

tent  instructor  is  more  efficient  than  the  untrained 
recruit. 

The  preceding  remarks  as  to  the  treatment  of  tubercu- 
losis in  sanatoria  illustrate  certain  well-known  features 
in  the  natural  history  of  this  disease.  In  the  majority 
of  instances  of  disease  recognised  under  present  con- 
ditions we  are  dealing  with  a  slowly  progressing  dis- 
ease. This  sometimes  become  spontaneously  arrested ; 
occasionally  it  may  be  arrested  or  its  course  delayed 
under  medical  treatment  at  home  associated  with  man- 
ageable changes  in  domestic  and  industrial  life.  In 
still  further  instances  it  may  be  arrested  by  treatment 
in  a  sanatorium;  while  for  other  cases  sanatorium 
treatment,  however  prolonged,  is  followed  by  only 
temporary  improvement,  and  the  chief  benefit  thus 
received  is  that  of  training  as  to  mode  of  life,  which 
might  have  been  secured  by  a  much  less  protracted 
stay  in  the  institution,  followed  by  measures  supple- 
menting sanatorium  treatment.  We  have  further  to 
recognise  the  fact  that,  under  present  conditions  of 
social  life  and  medical  practice,  many  tuberculous  pa- 
tients will  slowly,  by  intermittent  stages,  but  none  the 
less  surely,  die  from  tuberculosis  in  the  course  of  one, 
three  or  five  years.  Regard  must  be  paid  to  this  fact 
if  our  total  measures  for  the  control  of  tuberculosis 
are  to  be  successful. 


THE   CAUSATION   OF  TUBERCULOSIS  235 

Hospital  Treatment 

This  fact  emphasizes  the  importance  of  adequate 
hospital  treatment  for  all  patients  acutely  ill  or  bed- 
ridden, who  cannot  be  hygienically  treated  at  home; 
and  the  importance  becomes  evident  of  exercising 
complete  supervision  over  and  provision  for  the  whole 
of  the  sick  life  of  the  consumptive,  whether  he  is  trend- 
ing towards  complete  recovery  or  to  death. 

Such  complete  supervision  and  provision  necessi- 
tates further  development  in  three  directions  in  which 
beginnings  have  already  been  made : 

Industrial  Colonies 

These  are  the  provision  of  "  Farm  or  Industrial 
Colonies,"  the  adaptation  of  domestic  dwellings  to 
meet  the  special  needs  of  consumptives,  and  the  more 
complete  organization  of  "Care"  and  "After-care" 
arrangements. 

In  a  large  proportion  of  cases,  the  patient  on  leav- 
ing the  sanatorium  is  unable  at  once  to  embark  on  full 
work  without  risk  of  early  relapse,  or  to  refrain  from 
this  without  endangering  his  nutrition  and  that  of  his 
family.  His  work,  furthermore,  may  be  unsuitable 
for  a  consumptive. 

This  has  led  to  many  tentative  efforts  to  train  the 
consumptive  in  a  suitable  occupation  while  under  sana- 
torium treatment,  or  in  an  industrial  colony  which 
should  preferably  be  attached  to  or  in  close  commu- 


236  THE   CAUSATION   OF  TUBERCULOSIS 

nication  with  a  sanatorium,  in  order  that  the  patient 
may  continue  under  skilled  medical  supervision.  The 
graduated  labour  which  forms  part  of  the  routine 
method  of  treatment  in  many  sanatoria  can  be  made  a 
preparatory  stage  in  this  industrial  training.  The 
training  may  be  made  to  merge  into  the  pursuit  of  an 
actual  livelihood;  and  then  the  sanatorium  becomes 
an  industrial  colony.  Market  gardening,  pig-keeping, 
forestry,  and  other  occupations  may  be  thus  pursued 
for  protracted  periods,  if  the  patients  are  suitably  se- 
lected. The  ex-patients  continue  to  live  under  pro- 
tected conditions,  earning  part  at  least  of  their  liveli- 
hood. Attempts  in  this  direction  are  not  likely  to 
have  wide  success  unless  the  patient  is  re-instated  in 
his  family;  and  the  most  promising  efforts  are  those 
which  install  the  ex-consumptive  with  his  family  in  a 
cottage  near  a  sanatorium,  where  he  can  remain  under 
partial  medical  supervision,  while  engaged  in  his  daily 
work.  It  remains  to  be  seen  to  what  extent  such 
arrangements  are  practicable  on  a  considerable  scale, 
and  the  experiments  now  being  made  will  be  watched 
with  interest. 

Special  Dwellings  and  Help  in  Support 

An  alternative  to  the  "  colony  "  proposal,  which  will 

probably  be  found  practicable  in  a  much  larger  number 

of  cases  is  to  arrange  for  the  ex-patient  to  be  housed 

at  his  home  under  special  conditions  and  for  his  work 


THE   CAUSATION  OF  TUBERCULOSIS  237 

to  be  graduated  according  to  his  physical  condition, 
assistance  being  given  by  way  of  payment  of  rent,  or 
otherwise  to  ensure  that  the  patient  and  his  family 
live  under  satisfactory  conditions.  Proposals  have 
been  made  by  Dr.  Chapman  in  a  report  to  the  English 
Local  Government  Board  that  in  connection  with  new 
housing  schemes  a  certain  proportion  of  the  houses 
erected  should  have  rooms  providing  free  perflation 
of  air  reserved  for  consumptive  patients.  If  with  this 
is  combined  the  assistance  indicated  above,  the  risk  of 
the  ex-patient  relapsing  will  be  materially  reduced,  and 
the  risk  of  other  members  of  the  family  becoming 
consumptive  may  be  obviated. 

Whatever  methods  are  employed,  the  principle  al- 
ready enunciated  must  be  maintained  that  the  patient 
in  his  own  interest  and  in  that  of  his  family  must  be 
the  subject  of  uninterrupted  care  and  supervision. 

In  securing  this  end  Care  Committees  play  a  valua- 
ble part.  Owing  to  the  war  their  development  has 
been  retarded;  but  a  local  scheme  for  such  super- 
vision and  assistance  as  the  members  or  agents  of  a 
Care  Committee  can  give  forms  an  essential  part  of  a 
complete  tuberculosis  scheme. 

These  Committees  are  formed  of  non-official  per- 
sons, inasmuch  as  a  large  share  of  their  work  is  at 
present  beyond  the  scope  of  official  possibilities,  out- 
side the  poor-law  organization ;  they  can  help, 
(a)  in  obtaining  appropriate  work  for  the  ex-patients; 


238  THE   CAUSATION   OF  TUBERCULOSIS 

(&)  in  supplementing  his  wages; 

(c)  in  providing  separate  sleeping  accommodation  for 

the  patient,  additional  food  or  clothing,  or  in 
loaning  out  an  additional  bed  or  bedding ; 

(d)  in  aiding  the  family  during  the  absence  of  the 

patient  in  a  sanatorium,  and  thus  reducing  the 
temptation  to  terminate  institutional  treatment 
prematurely,  and 

(0)  in  encouraging  each  patient  to  take  the  necessary 
precautions  and  to  adopt  the  special  treatment 
recommended  for  him. 

Some  of  these  activities  overlap  into  the  activities 
of  the  tuberculosis  officer  and  of  the  visiting  nurse  of 
the  local  authority ;  but  there  need  be  no  practical  diffi- 
culty in  adjusting  this.  It  is  important  that  Care 
Committees  should  act  in  cooperation  with  local  au- 
thorities, insurance  committees,  and  charitable  agen- 
cies, and  should  have  representatives  of  these  bodies 
on  them.  The  medical  officer  of  health  and  tubercu- 
losis should  also  be  ex-officio  members  of  their  com- 
mittee. 

Summary. — The  preceding  review  of  the  problem  of 
tuberculosis  may  be  summarised  in  a  few  final  state- 
ments. 

i.  Our  knowledge  of  tuberculosis,  if  fully  applied 
by  combined  attack  on  the  disease  by  all  known 
methods,  is  adequate  to  secure  a  great  reduction  in 
its  prevalence,  if  not  its  absolute  abolition. 


THE   CAUSATION   OF  TUBERCULOSIS  239 

This  is  true,  although  certain  problems  respecting 
tuberculosis  still  need  elucidation,  e.g.,  as  to  improved 
methods  of  treating  the  diseases,  and  of  increasing 
individual  immunity  during  exposure  to  protracted 
infection. 

2.  Domestic  protection  is  at  once  practicable  against 
infected  cows'  milk;  and  control  of  this  source  of  in- 
fection at  its  source  is  also  practicable. 

3.  Of  the  circumstances  favouring  the  development 
of  pulmonary  tuberculosis  industrial  dust  and  domes- 
tic overcrowding  are  the  most  potent.     More  detailed 
and  systematic  supervision  of  factories  and  workshops 
is  needed,  followed  by  general  adoption  of  remedies, 
which  would  increase  industrial  efficiency  as  well  as 
reduce  tuberculosis. 

4.  Tuberculosis  is  especially  a  "  bedroom  infection." 
But  improvement  in  housing  is  a  dual  problem,  and  it 
is  a  blunder  to  assume  that  improved  housing,  so  long 
as  the  healthy  and  tuberculous  sick  continue  to  be 
housed  together,  will  produce  a  rapid  decline  in  the 
prevalence  of  tuberculosis.    Hospital  provision  for  the 
sick  is  as  necessary  as  improved  general  housing. 


CHAPTER  X 
CHILD  WELFARE  WORK  IN  ENGLAND* 

The  subject  of  child  welfare,  in  its  chief  develop- 
ments, cannot  be  separated  from  that  of  Public  Health, 
of  which  it  forms  a  constituent  part,  though  I  do  not 
ignore  the  fact  that  child  welfare  is  largely  dependent 
also  on  the  extent  to  which  child  labor  is  exploited, 
and  to  which  expectant  and  nursing  mothers, — as  also 
other  mothers  whose  extra-domestic  employment  or 
whose  employment  for  gain  is  within  the  home  itself, — 
involves  neglect  of  young  children. 

Improvement  in  child  welfare  has  occurred  as  the 
sanitary  and  social  progress  of  the  country  has  ad- 
vanced. Whereas  in  the  decade  1871-80,  when  money 
began  to  be  spent  more  freely  on  elementary  sanitary 
reform,  the  expectation  of  life  or  mean  after-lifetime 
at  birth  of  males  was  41.4  years  and  of  females  was 
44.6  years;  in  the  years  1910-12  these  had  increased 
to  51.5  and  55.4  years  respectively.  The  greater  part 
of  the  saving  of  life  which  this  addition  of  ten  years 
to  the  average  duration  of  life  was  the  result  of  re- 
duced mortality  in  children  under  five  years  of  age. 

1  Extracted  from  addresses  given  at  Conferences  held  by  the 
Children's  Bureau  of  the  Department  of  Labor,  Washington. 

240 


CHILD  WELFARE   WORK   IN   ENGLAND  24! 

The  first  direct  steps  towards  the  reduction  of  in- 
fant mortality  were  directed  against  epidemic  or  sum- 
mer diarrhoea.  Medical  officers  of  health  have  always 
been  required  in  their  annual  reports  to  summarize  the 
vital  statistics  in  their  districts ;  and  since  1905  a  more 
detailed  statement  of  infant  mortality  during  each  part 
of  infancy  has  been  required.  Annually,  therefore, 
as  well  as  when  they  received  the  weekly  returns  of 
deaths  from  the  local  registrars,  there  was  forced 
upon  their  attention  the  fact  that  deaths  of  infants 
under  one  year  of  age  formed  a  high  proportion  of 
total  deaths  at  all  ages  (12.9  per  cent,  in  1917),  and 
that  of  these  infantile  deaths  a  large  proportion  were 
caused  by  diarrhoea,  the  number  varying  with  the  tem- 
perature and  the  deficiency  of  rainfall  in  the  summer 
months.  In  1912,  a  year  of  relatively  small  mortality 
from  diarrhoea,  this  disease  caused  8.1  percent,  of  all 
deaths  under  one  year  of  age. 

For  many  years  past  it  has  been  customary  for  med- 
ical officers  of  health  to  issue  warnings  as  to  summer 
diarrhoea,  to  arrange  for  the  distribution  of  leaflets  of 
advice  concerning  the  disease,  and  to  urge  the  neces- 
sity of  more  thorough  cleanliness  both  municipal  and 
domestic  during  the  summer  months.  Even  before 
the  early  notification  of  births  became  obligatory,  in 
many  areas  the  addresses  of  infants  were  obtained 
from  the  registrars  of  births  and  special  visits  were 
made  to  the  mothers  of  infants  during  the  months  of 
17 


242  CHILD   WELFARE    WORK   IN    ENGLAND 

June  and  July  and  especially  to  the  mothers  of  those 
infants  who  were  known  to  be  artificially  fed. 

The  reports  of  medical  officers  of  health  of  many 
of  the  large  towns  from  1890  onwards  show  that  much 
valuable  work  was  being  accomplished,  and  the  way 
was  being  prepared  for  more  general  measures  against 
infant  mortality. 

The  importance  of  municipal  sanitation  in  aiding 
the  elimination  of  diarrhceal  mortality  is  illustrated  in 
the  experience  of  many  towns,  and  strikingly  by  the 
comparative  experience  of  Leicester  and  Nottingham. 
The  chief  difference  between  the  sanitary  condition  of 
the  twp  towns  was  that  in  Nottingham  in  1909  pail 
closets  still  served  more  than  half  the  houses,  while 
Leicester  had  abandoned  this  system  entirely,  substi- 
tuting water-closets.  Between  1889-93  and  1909  the 
diarrhceal  mortality  in  Leicester  had  declined  52  per 
cent. ;  in  Nottingham  it  had  only  declined  4  per  cent. 

Diarrhoea  is  not  the  only  disease  of  infancy  which 
can  be  greatly  diminished  by  improved  public  health 
administration.  Tuberculosis  and  whooping  cough 
and  measles  figure  largely  in  the  infantile  death  re- 
turns. Over  21  per  cent,  of  the  total  deaths  in  infancy 
are  due  to  these  three  diseases  and  to  diarrhoea.  The 
amount  of  syphilis  appearing  in  the  death-returns  is 
small ;  but  its  actual  amount  is  much  greater  than  the 
figures  show.  If  pneumonia  and  bronchitis,  which 
account  for  19  per  cent,  of  the  deaths  in  infancy,  be 


CHILD   WELFARE   WORK   IN   ENGLAND  243 

regarded — as  they  should — as  infective  diseases,  then 
it  may  be  said  that  the  problem  of  saving  child  life  and 
securing  the  correlative  improvement  in  the  standard 
of  health  of  children  who  survive  to  higher  ages,  con- 
sists very  largely  in  the  prevention  of  infections,  in- 
cluding diarrhceal  diseases  and  acute  respiratory  dis- 
eases. 

It  follows  from  this  that  even  if  the  limited  and 
erroneous  view  be  taken  that  Sanitary  Authorities  are 
concerned  only  with  the  prevention  of  infectious  dis- 
eases, the  reduction  of  infant  mortality  is  a  duty  de- 
volving on  these  authorities,  and  cannot  be  effectively 
carried  out  without  their  cooperation.  Voluntary 
effort  must  therefore  always,  in  large  measure,  be 
directed  towards  stimulating  local  authorities  to  per- 
form their  duties. 

The  influence  of  diarrhoeal  summer  mortality  on  the 
progress  of  child  welfare  work  is  further  shown  by 
the  fact  that  among  the  earliest  efforts  were  those  to 
provide  pure  cows'  milk  to  infants.  In  England  offi- 
cial Milk  Depots  for  this  purpose  were  never  numer- 
ous ;  and  little  voluntary  effort  went  in  this  direction. 
There  now  remain  very  few  such  Milk  Depots;  but 
many  local  authorities  provide  milk,  more  particularly 
dried  milk,  to  infants  for  whom  it  is  specially  pre- 
scribed at  Infant  Consultations.  Early  investigations 
at  Brighton  and  elsewhere  showed  that  the  mortality 
of  infants  fed  on  condensed  milk, — chiefly  of  the 


244  CHILD  WELFARE   WORK   IN   ENGLAND 

sweetened  variety, — was  greater  than  that  of  infants 
fed  on  fresh  cows'  milk,  and  directed  attention  to  the 
supreme  importance  of  domestic  cleanliness  in  the 
prevention  of  summer  diarrhoea.  The  Milk  Depots 
and  the  concurrent  agitation  for  purer  cows'  milk 
served  a  useful  purpose ;  though  it  cannot  yet  be  said 
that  the  cows'  milk  ordinarily  supplied  in  England  is 
satisfactorily  clean. 

It  became  evident  ere  long  that  the  broadcast  distri- 
bution of  instructions  as  to  how  cows'  milk  might 
safely  be  stored  and  prepared  for  infants  had  but  a 
limited  utility,  and  that  the  directions  given  were  liable 
to  be  misinterpreted  by  mothers  as  an  encouragement 
to  abandon  breast-feeding;  and  there  is  reason  to  be- 
lieve that  these  directions  did  sometimes  have  this 
effect.  Hence  the  importance  of  the  work  initiated  by 
the  late  Dr.  Sykes  at  the  St.  Pancras  School  for 
Mothers,  which  brought  into  relief  the  importance  of 
encouraging  breast-feeding  by  every  possible  means. 
In  towns  in  which  the  aided  supply  of  milk  was  con- 
tinued, advice  as  to  its  use  was  also  initiated ;  and  thus 
gradually  Infant  Consultations,  in  which  the  main  ele- 
ment was  the  giving  of  individual  advice  and  treatment 
as  required,  superseded  Milk  Depots,  and  were  estab- 
lished in  very  large  numbers  where  Milk  Depots  had 
never  been  started.  These  had  educational  as  well 
as  medical  and  hygienic  activities;  and  there  need  be 
no  dispute  as  to  the  relative  value  of  these  two  aspects 


CHILD   WELFARE   WORK   IN   ENGLAND  245 

of  the  work  of  Infant  Consultations  (also  known  as 
Schools  for  Mothers,  Child  Welfare  Centres,  Baby 
Weighings,  Mothers'  Welcomes,  etc.)  ;  for  whether 
advice  and  instruction  are  given  to  the  individual 
mother  or  to  mothers  collectively, — or  as  is  advisable 
in  both  ways, — it  should  be  exactly  the  advice  which  a 
physician  skilled  in  the  hygiene  of  infancy  as  well  as 
in  the  treatment  of  infantile  complaints  would  give  to 
his  individual  patient.  In  this  sense  it  remains  true, 
as  Professor  Budin,  the  distinguished  founder  of  In- 
fant Consultations  said:  "An  infant  consultation  is 
worth  precisely  as  much  as  the  presiding  physician." 
This  is  true  whether  it  is  possible  to  arrange  for  a  phy- 
sician to  be  present  at  each  meeting  of  a  Child  Welfare 
Centre ;  or  whether,  as  has  happened  during  the  Great 
War  in  England,  nurses  or  health  visitors  trained 
under  such  a  physician  have  given  hygienic  advice  in 
his  absence. 

The  Notification  of  Births 

For  many  years  before  the  Notification  of  Births 
Act  was  passed,  it  had  been  customary,  especially  in 
towns,  to  arrange  for  inquiry  by  a  sanitary  inspector 
or  female  visitor  into  death  occurring  under  one  year 
of  age,  and  in  many  instances  for  the  giving  of  sys- 
tematic advice  to  mothers  concerning  their  infants. 
More  than  twenty  years  ago  the  Manchester  and  Sal- 
form  Sanitary  Association  had  initiated  a  system  of 


246  CHILD   WELFARE   WORK   IN   ENGLAND 

home  visitation  by  volunteer  ladies  and  by  women 
workers  paid  by  the  Association  who  went  from  house 
to  house,  gave  elementary  sanitary  advice,  and  re- 
ported serious  defects  to  the  Sanitary  Authority.  The 
City  Council  at  an  early  stage  showed  its  appreciation 
of  the  importance  of  this  work  by  giving  grants 
towards  the  expenditure  incurred. 

In  order  to  enable  early  visits  to  be  made,  the  town 
council  of  Salford  had  begun  as  early  as  1899  a  system 
of  voluntary  notification  of  births  by  midwives. 

Prior  to  the  stage  at  which  early  notifications  of 
births  was  obtained,  the  medical  officer  of  health  was 
dependent  for  his  information  on  the  registration  of 
births,  for  which  an  interval  of  six  weeks  after  birth 
was  permitted  before  it  became  compulsory.  During 
this  interval  a  large  proportion  of  the  total  mortality 
of  infancy  had  occurred, — approximately  one-fifth  of 
the  total  deaths  in  ths  first  year  after  birth  occur  in 
the  first  week  and  one-third  in  the  first  month  after 
birth, — and  the  possibility  of  successfully  influencing 
the  mother  to  continue  breast-feeding  had  gone.  The 
action  of  the  town  of  Huddersfield  in  1906  in  obtain- 
ing Parliamentary  power  to  secure  the  compulsory 
notification  of  births  within  thirty-six  hours  of  birth 
represented  a  rapid  growth  of  opinion  based  on  expe- 
rience in  that  and  other  towns  to  the  effect  that  in  the 
absence  of  early  information  of  birth  the  necessary 
sanitary  precautions  and  counsel  as  to  personal  hy- 


CHILD   WELFARE   WORK   IN    ENGLAND  247 

giene  could  not  be  given  with  the  greatest  prospect  of 
success.  This  local  pioneer  work  doubtless  facilitated 
the  passing  of  the  Notification  of  Births  Act  in  1907- 

Much  important  work  followed  the  notification  of 
births.  Home  visits  to  the  mother  were  regarded  and 
continue  to  be  regarded  as  the  most  important  part  of 
this  work ;  but  there  also  grew  up  rapidly  the  present 
system  of  Infant  Consultations  and  similar  organi- 
zations. 

The  Notification  of  Births  (Extension)  Act,  1915, 
not  only  made  the  enforcement  of  this  act  universal, 
but  it  also  empowered  each  local  authority  adminis- 
tering the  Act  to  exercise  any  powers  which  a  sanitary 
authority  possesses  under  the  Public  Health  Acts  "  for 
the  purpose  of  the  care  of  expectant  mothers,  nursing 
mothers,  and  young  children."  In  drawing  the  atten- 
tion of  Local  Authorities  to  the  terms  of  the  Act  the 
Local  Government  Board,  as  well  as  earlier  in  the  war, 
deprecated  false  economy  during  the  war.  They  said : 

At  a  time  like  the  present  the  urgent  need  for  taking  all 
possible  steps  to  secure  the  health  of  mothers  and  children  and 
to  diminish  ante-natal  and  post-natal  infant  mortality  is  ob- 
vious, and  the  Board  are  confident  that  they  can  rely  upon 
local  authorities  making  the  fullest  use  of  the  powers  con- 
ferred on  them. 

The  Board  in  the  same  circular  laid  stress  on  "the 
importance  of  linking  up  this  work  with  the  other 


248  CHILD  WELFARE  WORK   IN   ENGLAND 

medical  and  sanitary  services  provided  by  local  au- 
thorities under  the  Public  Health  and  other  Acts." 

The  passing  of  this  Act  has  been  followed  by  an 
increasingly  rapid  development  of  Maternity  and  Child 
Welfare  work,  and  the  Maternity  and  Child  Welfare 
Act  passed  in  August,  1918,  made  it  obligatory  on 
each  Council  exercising  powers  under  the  Act  to  ap- 
point a  Maternity  and  Child  Welfare  Committee, 
which  must  include  at  least  two  women,  and  may  in- 
clude persons  specially  qualified  by  training  or  expe- 
rience in  subjects  relating  to  health  and  maternity  who 
are  not  members  of  the  Council. 

In  the  circular  letter  sent  out  to  local  authorities  ex- 
plaining the  new  Act,  the  Local  Government  Board 
reemphasizes  its  previously  stated  views  that  child 
welfare  work  was  second  only  in  importance  to  direct 
war  work,  and  was  really  a  "measure  of  war  emer- 
gence," and  added : 

although  we  have  enjoined  as  local  authorities  the  necessity 
of  the  strictest  of  economy  in  public  expenditure,  we  have 
urged  increased  activity  in  work  which  has  for  its  object  the 
preservation  of  infant  life  and  health.  We  are  glad  to  note 
that  the  great  majority  of  local  authorities  have  realized  the 
value  of  continuing  and  extending  their  efforts  for  child  wel- 
fare at  the  present  time. 

The  Causes  of  Child  Mortality 

For  detailed  consideration  of  the  causes  of  infant 
mortality  and  of  mortality  during  the  next  four  years 


CHILD  WELFARE   WORK   IN   ENGLAND  249 

of  life  in  England  and  Wales,  the  reader  may  be  re- 
ferred to  official  reports  by  the  writer. 

No  consistent  and  continuous  decline  had  taken 
place  in  infant  mortality  prior  to  1900,  although  there 
had  been  marked  reduction  of  the  mortality  in  each 
of  the  next  four  years  of  life.  This  difference  corre- 
sponds in  the  main  with  the  facts  that  greater  success 
had  been  achieved  in  the  general  measures  of  sanita- 
tion and  in  the  reduction  of  prevalence  of  and  mor- 
tality from  such  infectious  diseases  as  scarlet  fever, 
diphtheria,  and  enteric  fever,  than  in  respect  of  the 
special  causes  of  mortality  in  infancy.  These  special 
causes  may  be  placed  under  three  headings :  First,  in- 
fections,— acute  respiratory  diseases,  measles,  whoop- 
ing cough,  syphilis,  tuberculosis,  and  diarrhoea ;  second, 
errors  of  nutrition,  due  largely  to  poverty,  to  mis- 
management, and  to  imperfect  provision  of  facilities 
for  healthy  family  life ;  and  third,  developmental  con- 
ditions present  at  the  birth  of  the  infants.  Under 
none  of  these  headings  had  marked  success  been 
achieved  prior  to  1900,  though  the  steady  work  de- 
voted to  the  subject  of  diarrhoea  had  already  begun  to 
show  fruit. 

The  statistics  of  infant  mortality  may  be  stated  as 
follows : 


25O  CHILD  WELFARE  WORK   IN   ENGLAND 

England  and  Wales 

Deaths  of  Infants  under 
Period  i  Year  per  1,000  Births 

1896-1900  156 

I90I-I905  138 

IOO6-I9IO  117 

1911  130 

1912   95 

1913  108 

1914  105 

1915  no 

1916  91 

1917  96 

1918 97 

The  above  are  the  crude  rates,  the  infantile  death- 
rate  being  stated  by  the  usual  method  per  1,000  births 
during  the  same  year.  Owing  to  the  great  decline  of 
births  during  the  war,  this  method  overstates  the  in- 
fant mortality  in  recent  years.  In  a  table  given  in  the 
Registrar-General's  annual  report  for  1917,  this  un- 
usual source  of  error  is  corrected.  When  this  is  done, 
and  the  infantile  deaths  are  stated  "per  1,000  of  popu- 
lation aged  o-i,"  the  rates  for  the  years  1912-17 
inclusive  in  successive  years  became  respectively 

104,  117,  113,  ill,  98,  and  94. 

In  other  words,  there  has  been  a  steady  and  uninter- 
rupted decline  in  the  death-rate  of  infants  during  the 
war. 

This  decline  has  followed  similar  declines  in  preced- 
ing years,  and  it  is  to  be  noted  that  much  of  this  decline 


CHILD  WELFARE  WORK   IN   ENGLAND  25! 

occurred  during  the  period  when  the  hygienic  work 
effecting  child- welfare  was  confined  to  general  public 
health  measures.  Thus  it  anticipated  the  more  direct 
and  active  measures  adopted  by  voluntary  societies 
and  by  local  authorities  for  the  prevention  of  infant 
mortality.  Comparing  the  five  year  periods  1896- 
1900  and  1901-05,  a  decrease  in  the  death-rate  of  12 
per  cent,  is  seen ;  comparing  1901-05  with  1906-10,  a 
decline  of  15  per  cent,  occurred;  comparing  1906-10 
with  the  average  experience  of  the  three  years  1911- 
13  mortality  declined  5  per  cent.;  comparing  these 
three  years  with  the  average  experience  of  the  five 
years  1914-18,  during  which  war  conditions  prevailed 
more  or  less,  a  reduction  9  per  cent,  was  experienced. 
The  actual  reduction  during  war  time  is  greater  than 
is  indicated  by  these  percentages,  when  allowance  is 
made  for  the  statistical  error  indicated  above.  The 
exceptional  experience  of  the  year  1911  illustrates  one 
of  the  chief  sources  of  error  in  forming  conclusions 
on  the  experience  of  a  single  year.  In  this  year  the 
summer  was  excessively  hot,  and  summer  diarrhoea 
prevailed  to  an  exceptional  extent ;  and  the  illustration 
is  important,  as  serving  to  remind  us  of  the  limitations 
of  the  value  of  statistical  tests  and  of  the  fact  that 
increase  of  good  work  tending  to  improve  child  life 
may  be  associated  temporarily  with  increase  of  total 
infant  mortality. 


252  CHILD  WELFARE  WORK   IN   ENGLAND 

The  Influence  of  School  Medical  Inspection 

In  the  development  of  child  welfare  work  in  Eng- 
land important  place  must  be  given  to  the  system  of 
medical  inspection  of  school  children  initiated  in  1907. 
The  numerous  physical  defects  found  in  school  chil- 
dren have  led  to  the  beginning  of  measures  for  reme- 
dial action,  confined  in  some  areas  to  measures  for 
securing  greater  cleanliness  and  the  treatment  of  minor 
skin  diseases;  but  extending  in  other  areas  to  such 
measures  as  the  remedial  treatment  of  adenoids,  the 
cure  of  ringworm,  the  correction  of  errors  of  refrac- 
tion, and  the  provision  of  dental  treatment.  Perhaps 
the  chief  value  of  the  system  of  medical  inspection  of 
school  children  has  been  the  fact  that  it  has  demon- 
strated the  extent  to  which  children  when  they  first 
come  to  school  are  already  suffering  from  physical  dis- 
ease which  might  have  been  prevented  or  minimized 
by  attention  in  the  pre-school  period.  The  informa- 
tion thus  accumulated  has  had  much  influence  in  en- 
couraging the  institution  of  Infant  Consultations,  with 
a  view  to  the  early  discovery  of  disease  or  of  tendency 
to  disease. 

The  Influence  of  Statistical  Studies 

The  intensive  study  of  our  national  and  of  local  vital 
statistics  has  also  had  a  most  important  bearing  on  the 
further  development  of  maternity  and  child  welfare 


CHILD   WELFARE   WORK    IN   ENGLAND  253 

work.  In  successive  official  reports  it  has  been  shown 
that  infant  mortality  varies  greatly  in  different  parts 
of  the  country,  irrespective  of  climatic  conditions; 
that  it  varies  greatly  in  different  parts  of  the  same 
town,  in  accordance  with  variations  in  respect  of  in- 
dustrial and  housing  conditions,  of  local  sanitation,  of 
poverty  and  alcoholism ;  that  the  variations  extend  to 
different  portions  of  infant  life,  the  death-rate  in  in- 
fants under  a  week,  or  under  a  month  in  age,  for  in- 
stance, being  two  or  three  times  as  high  in  some  areas 
as  in  others;  and  that  the  distribution  of  special  dis- 
eases in  infancy  similarly  varies  greatly.  Intensive 
studies  of  infant  mortality  on  these  and  other  lines 
have  pointed  plainly  the  directions  in  which  preventive 
work  is  especially  called  for;  and  have  incidentally 
demonstrated  the  fundamental  value  of  accurate  sta- 
tistics of  births  and  of  deaths  in  the  child  welfare 
campaign.  Surveys  of  local  conditions  both  statistical 
and  based  on  actual  local  observations  form  an  indis- 
pensable preliminary  to  and  concomitant  of  good  child 
welfare  work;  and  it  is  to  combined  work  on  these 
lines  that  the  improvement  of  recent  years  is  largely 
attributable.  To  act  helpfully  we  must  know  thor- 
oughly the  summation  of  conditions  which  form  the 
evil  to  be  attacked. 

One  important  result  of  investigations  such  as  those 
already  mentioned  has  been  to  bring  more  clearly  into 
relief  the  fact,  which  previously  had  been  partially 


254  CHILD   WELFARE  WORK   IN   ENGLAND 

neglected,  that  child  welfare  work  can  only  succeed 
in  so  far  as  the  welfare  of  the  mother  is  also  main- 
tained. 

This  may  imply  extensions  of  work  involving  serious 
economic  considerations;  but  apart  from  such  possi- 
bilities and  apart  from  questions  of  housing,  and  of 
provision  of  additional  domestic  facilities  for  assisting 
the  overworked  mother,  there  is  ample  evidence  that 
medical  and  hygienic  measures  by  themselves  can  do 
much  to  relieve  the  excessive  strain  on  the  mother 
which  childbearing  under  present  conditions  often  in- 
volves. 

The  Course  of  Mortality  from  Childbearing 

The  general  course  of  mortality  from  childbearing 
(including  deaths  ascribable  to  pregnancy)  in  England 
and  Wales  is  shown  by  the  following  table : 

Average  Annual  Death-rates  per  100,000  births  from 


5  years,  1902-06   

Puerperal 
Septic 
Diseases 

185 

Other  Diseases 
of  Pregnancy 
and  Childbirth 

228 

5  years,  1907-11    

.    I"i2 

21  C 

3  years,  1912-14   

.    148 

277 

2  years,  1015-16   . 

.    I« 

27Q 

It  will  be  noted  that  although  there  has  been  a 
marked  decline  of  deaths  from  puerperal  sepsis,  the 
death-rate  from  other  complications  of  childbearing 
has  not  declined.  The  decline  in  puerperal  sepsis  is 


CHILD  WELFARE  WORK   IN   ENGLAND  255 

general  throughout  the  country,  and  evidences  the 
greater  care  in  midwifery  both  on  the  part  of  doctors 
and  of  midwives.  The  administration  of  the  Mid- 
wives  Act,  1902,  has  doubtless  done  much  to  secure 
this.  The  death-rate  from  conditions  other  than  puer- 
peral fever  continues  to  differ  greatly  throughout  the 
country.  It  is  highest  in  Welsh  counties,  Westmore- 
land, Lancashire  and  Cheshire  coming  next  in  order 
of  unfavourable  portion ;  in  many  industrial,  including 
textile,  towns  it  is  also  excessive.  The  general  con- 
clusion reached  by  the  writer  in  an  elaborate  official 
report  on  the  subject  is  that  "  the  quality  and  availa- 
bility of  skilled  assistance  before,  during,  and  after 
childbirth  are  probably  the  most  important  factors  in 
determining  the  remarkable  and  serious  differences  in 
respect  of  mortality  from  childbearing  shown  in  the 
report." — "  The  differences  are  caused  in  the  main  by 
differences  in  availability  of  skilled  assistance  when 
needed  in  pregnancy,  and  at  and  after  childbirth." 

The  Midwives  Act,  1902 

This  Act  forbade  any  woman  after  April  I,  1906, 
who  was  not  certified  under  the  Act,  from  using  the 
title  of  midwife  or  any  similar  description  of  herself. 
It  forbade  after  April  I,  1910,  any  such  woman  from 
"habitually  and  for  gain  attending  women  in  child- 
birth, except  under  the  direction  of  a  qualified  medical 
practitioner  " ;  and  it  forbade  any  certified  midwife  to 


256  CHILD  WELFARE   WORK   IN   ENGLAND 

use  an  uncertified  person  as  her  substitute.  The  Act 
defined  the  limits  of  function  of  the  midwife  by  stating 
that  the  Act  did  not  confer  upon  her  any  title  to  give 
certificates  of  death  or  of  still-birth,  or  to  take  charge 
of  any  abnormality  or  disease  in  connection  with  par- 
turition. 

The  Act  set  up  the  Central  Midwives  Board,  giving 
it  special  disciplinary  powers  over  midwives.  It  also 
imposed  on  county  councils  and  the  councils  of  county 
boroughs  the  duty  of  supervising  the  work  of  mid- 
wives.  For  further  details  the  Act  itself  and  the 
Rules  of  the  Central  Midwives  Board  made  under  the 
Act  should  be  consulted. 

The  Midwives  Act,  1918,  gave  further  powers  to  the 
Central  Midwives  Board  and  to  local  supervising  au- 
thorities, and  made  it  the  duty  of  the  latter  to  pay  the 
fee  of  a  doctor  called  in  by  a  midwife  in  any  of  the 
emergencies  for  which  Rules  are  made  by  the  Central 
Midwives  Board,  the  fee  paid  to  be  in  accordance  with 
a  scale  prescribed  by  the  Ministry  of  Health. 

As  at  least  three-fourths  of  the  total  births  in  Eng- 
land and  Wales  are  attended  by  midwives  with  or 
without  the  assistance  of  doctors,  their  work  has  great 
importance  in  relation  to  the  reduction  of  maternal 
disablement  and  mortality  and  to  the  prevention  of 
early  infant  mortality,  and  it  is  of  happy  augury  that 
they  are  being  enlisted  more  and  more  in  official  work 
for  safeguarding  the  health  of  the  mother  and  her  un-' 


CHILD  WELFARE  WORK   IN   ENGLAND  257 

born  or  recently  delivered  infant.  An  important  re- 
cent addition  has  been  made  to  the  rules  of  the  Central 
Midwives  Board,  which  makes  it  obligatory  on  the 
midwife  to  notify  to  the  medical  officer  of  health  any 
instance,  while  the  patient  is  under  her  charge,  in  which 
for  any  reason  breast-feeding  has  been  discontinued. 

Administrative  Work. — Largely  through  the  ma- 
chinery provided  by  the  Midwives  Act  and  the  Noti- 
fication of  Births  Act  a  system  of  supervision  of  ma- 
ternity and  child  welfare  has  been  organized  in  every 
county  and  county  'borough,  and  this  has  been  respon- 
sible for  a  large  share  of  the  improvement  experienced 
in  recent  years.  The  character  and  extent  of  develop- 
ment of  the  work  varies  greatly  in  different  centres; 
and  as  a  rule  the  work  is  more  fully  developed  in 
county  boroughs  than  in  counties.  In  county  dis- 
tricts it  has  sometimes  been  found  necessary  to  unite 
the  offices  of  assistant  inspector  of  midwives,  infant 
visitor  and  tuberculosis  visitor  in  one  adequately 
trained  health  visitor,  thus  saving  time  in  travelling  by 
enabling  the  visitor  to  have  a  smaller  district  allotted 
to  her  than  if  she  undertook  only  one  branch  of  work. 
In  some  counties  the  school  nurse's  work  is  also  under- 
taken by  the  health  visitor.  In  some  country  areas 
arrangements  have  been  made  for  infant  visiting  to 
be  carried  out  by  district  nurses  who  are  also  midwives. 

Voluntary  Workers. — Much  of  the  success  so  far 
achieved  in  improving  the  health  conditions  of  in- 
18 


258  CHILD  WELFARE   WORK   IN   ENGLAND 

fancy  and  childhood  has  been  secured  by  cooperation 
between  voluntary  and  official  health  visitors.  Excel- 
lent work  has  been  done  by  local  and  other  societies, 
particularly  during  the  last  ten  years,  in  educating 
public  opinion  and  in  direct  assistance  to  mothers  and 
their  infants.  It  is  essential  that  such  voluntary  work 
should  have  a  nucleus  of  highly  trained  and  well-paid 
workers ;  but  given  this  condition,  a  large  amount  of 
good  work  can  be  accomplished  by  voluntary  aid. 

The  main  work  has  been  that  of  the  health  visitor. 
The  details  of  this  work,  the  conditions  of  qualification 
of  workers,  the  number  of  visits  which  it  is  desirable 
to  make,  the  character  of  the  advice  intended  to  be 
given  at  these  visits  are  set  out  in  an  official  memo- 
randum of  the  Medical  Officer  of  the  Local  Govern- 
ment Board  and  it  is  unnecessary  to  repeat  this  infor- 
mation in  these  pages. 

A  similar  remark  applies  to  the  next  most  important 
development  of  work,  the  institution  of  Maternity  and 
Child  Welfare  Centres.  The  conditions  of  work  of 
these  institutions  are  set  out  in  the  same  document. 

Training  and  Provision  of  Midwives 

The  provision  of  additional  trained  midwives  is  a 
pressing  problem.  The  increased  cost  of  living,  longer 
training  required,  and  the  rapid  development  of  less 
laborious  and  more  lucrative  occupations,  have  made  it 
difficult  to  secure  women  to  train  as  midwives,  or  to 


CHILD  WELFARE   WORK   IN   ENGLAND  259 

continue  to  practise  in  this  capacity  after  qualification. 
In  many  industrial  areas  the  older  bond  fide  midwife 
is  preferred,  although  it  is  the  almost  universal  expe- 
rience that  the  trained  midwife  more  quickly  detects 
conditions  endangering  the  life  of  the  mother  or  in- 
fant, and  sends  for  medical  help.  In  order  to  encour- 
age further  the  supply  of  practising  midwives,  the 
government  gives  grants  for  increased  remuneration 
to  midwives  newly  appointed  by  local  authorities,  suffi- 
cient to  recoup  them  in  the  course  of  a  few  years' 
service  for  the  cost  of  their  training. 

At  a  recent  date,  of  some  30,543  trained  midwives 
on  the  Roll,  only  6,754  were  returned  as  being  in  actual 
practice  as  such. 

In  order  to  make  midwives  available  for  all  women 
needing  them,  the  Board  repays  to  local  authorities 
and  voluntary  associations  half  the  cost  of  the  pro- 
vision of  a  midwife  for  necessitous  women.  During 
the  Great  War  a  woman  might  receive  assistance  in 
her  confinement  from  several  central  sources;  for  in 
addition  to  the  above 

1 i )  If  she  was  the  wife  of  an  insured  person,  or  if  she 

herself  is  insured,  she  received  under  the  con- 
ditions of  the  National  (Health)  Insurance  Act 
305  in  cash,  or  if  she  is  insured  and  the  wife  of 
an  insured  person  6os.  in  cash. 

(2)  If  she  was  the  wife  of  a  soldier  or  sailor  and  not 

entitled  to  maternity  benefit  she  received  from 


26O  CHILD  WELFARE   WORK   IN   ENGLAND 

IDS.  per  week  up  to  £2  from  the  Local  Pensions 
Committee. 

(3)  If  she  was  a  munition  worker  she  might  be  aided 

under  a  scheme  provided  under  the  Ministry 
of  Munitions. 

(4)  She  also  might  obtain  priority  for  the  supply  of 

milk,  or  obtain  free  milk  or  milk  at  cost  price 
under  the  Local  Committee  Board  Food  Con- 
trol Order,  No.  I,  1918,  empowering  local  au- 
thorities to  supply  milk  and  food  and  an  extra 
ration  under  the  Food  Controller's  Order.  In 
addition,  after  confinement  she  had  available 
the  ration  apportioned  to  the  infant  and  its 
allowance  of  milk  under  the  priority  scheme. 

There  was  evidently  need  for  simplification  and  uni- 
fication of  effort  in  the  above  cases. 

In  many  instances  maternity  nursing  is  required. 
The  midwife  may  have  too  many  patients  to  be  able 
to  give  this  during  the  ten  days  in  which  she  is  in 
charge  of  the  patient ;  and  even  when  she  carries  out 
her  duty  in  this  respect  in  accordance  with  the  Rules 
of  the  Central  Midwives  Board  additional  help  is  re- 
quired in  the  feeding  and  care  of  the  mother  and  in- 
fant, and  in  the  care  of  the  household.  Often  also 
nursing  is  required  for  both  mother  and  infant  for  a 
considerable  period  beyond  the  ten  days.  For  these 
persons  the  government  gives  grants  for  maternity 
nursing  and  for  "  home  helps." 


CHILD  WELFARE  WORK   IN   ENGLAND  26 1 

Even  when  all  the  above  requirements  are  or  can  be 
fulfilled,  there  remain  a  large  number  of  cases  of  preg- 
nant women,  and  especially  of  unmarried  women,  who 
cannot  be  satisfactorily  confined  at  home,  either  be- 
cause of  their  social  or  sanitary  circumstances,  or  be- 
cause abnormal  or  complicated  childbirth  is  expected. 
For  such  cases  hospital  provision  is  needed.  This  is 
one  of  the  most  urgent  requirements  of  the  present 
time. 

Under  present  conditions,  institutional  lying-in  pro- 
vision is  chiefly  voluntary  in  character;  and  the  gov- 
ernment has  advised  local  authorities  to  contract  for 
its  use,  rather  than  wait  for  the  erection  of  special 
hospitals.  In  other  instances  houses  are  being  taken 
and  adapted  as  maternity  homes. 

Ante-natal  Work 

The  progress  made  in  the  organisation  of  ante-natal 
work  is  slow  for  reasons  which  are  fairly  obvious. 
There  has  been  difficulty  under  war  conditions  in  se- 
curing assistance  from  doctors  and  midwives.  There 
is  the  well-known  difficulty  as  to  notification  of  preg- 
nancy, which  the  government  has  not  encouraged,  ex- 
cept when  the  definite  consent  of  the  mother  has  been 
previously  obtained.  The  facilities  for  help  provided 
at  the  Centre  have  in  some  areas  attracted  patients; 
and  health  visitors  and  midwives  have  done  much  in 
other  areas  to  persuade  mothers  of  the  advisability  of 


262  CHILD   WELFARE   WORK    IN   ENGLAND 

safeguarding  themselves  against  possible  complica- 
tions, as  well  as  of  securing  adequate  preparation  for 
the  lying-in  period. 

This  subject  is  closely  associated  with  that  of  abor- 
tions, stillbirths,  and  deaths  in  the  first  two  weeks  after 
birth.  One  of  the  most  promising  methods  for  secur- 
ing the  sound  development  of  ante-natal  work  con- 
sists in  the  investigation  of  stillbirths  and  early  infant 
mortality.  When  these  inquiries  are  made  mothers 
can  be  induced  to  obtain  medical  advice  not  only  at  the 
time,  but  also  in  the  event  of  a  subsequent' pregnancy . 
The  investigation  at  the  patient's  home  of  all  such 
cases  and  assistance  in  prevention  of  recurrence  of 
unnecessary  ante-natal,  natal,  and  early  post-natal 
deaths  have  as  great  an  importance  as  the  building  up 
of  a  successful  ante-natal  clinic.  The  anti-syphilis 
work  now  being  carried  on  will  help  greatly  in  this 
direction. 

Dental  Assistance 

There  has  been  a  large  extension  of  dental  assistance 
at  Centres  for  expectant  and  for  nursing  mothers, 
and  for  children,  especially  in  the  metropolis  and  its 
vicinity.  The  government  has  lately  extended  its 
grant  to  cover  dentures  for  mothers  who  are  nursing 
or  pregnant,  if  the  medical  officer  of  the  Centre  is 
satisfied  that  the  woman's  health  will  be  materially 
improved  by  the  denture,  and  that  she  is  unable  to  pro- 
vide it  for  herself. 


CHILD   WELFARE   WORK   IN    ENGLAND  263 

Creches 

Creches  and  day  nurseries  may  be  expected  to  exer- 
cise influence  in  educating  mothers  in  the  care  of  their 
children.  For  this  purpose  it  is  very  desirable  to  have 
the  creche  attached  to  or  near  an  infant  welfare  centre. 

These  creches,  unless  managed  with  the  most  rigid 
medical  and  general  cleanliness,  are  very  apt  to  spread 
infectious  diseases ;  not  merely  such  diseases  as  whoop- 
ing cough,  measles,  and  chickenpox,  but  also  catarrhal 
and  diarrhceal  diseases.  In  the  prevention  of  all  of 
these  the  enforcement  of  the  strictest  cleanliness  is 
essential,  especially  during  the  summer  months  for 
the  last  named  diseases.  For  the  prevention  of  ca- 
tarrhal infections,  it  is  essential  that  the  creche  should 
be  conducted,  so  far  as  practicable,  on  strict  open-air 
lines.  Open-air  creches  give  admirable  occasional  re- 
lief to  mothers,  even  when  these  do  not  go  out  to  work. 
The  "toddler's  playground"  is  a  blessing  to  all  con- 
cerned, but  the  indoor  creche  may  be,  and  often  is, 
mischievous.  The  risks  are  greatly  reduced  by  insist- 
ing on  open-air  conditions  and  by  not  allowing  large 
groups  of  children  to  come  together.  Smaller  groups 
mean  greatly  decreased  possibility  of  cross-infection. 

Observation  Beds  at  Child  Welfare  Centres 
At  infant  welfare  centres  infants  are  not  infre- 
quently seen  who  fail  to  make  progress  while  living  at 
home,  and  who  yet  are  not  ill  enough  to  be  sent  to  a 


264  CHILD  WELFARE   WORK   IN   ENGLAND 

hospital.  This  especially  applies  to  cases  of  defective 
nutrition.  For  these  cases  beds  in  connection  with 
centres  have  been  found  to  be  necessary  for  observa- 
tion purposes  and  to  initiate  further  treatment.  In 
some  instances,  especially  for  failure  of  breast-feeding, 
it  is  advisable  to  admit  the  mother  with  the  infant. 

On  July  30,  1914,  the  Local  Government  Board  sent 
a  circular  letter  and  a  covering  memorandum  by  their 
Medical  Officer  which  may  be  claimed  to  have  been  the 
starting  point  of  maternity  and  child  welfare  work  on 
a  larger  scale,  more  generally  distributed  throughout 
the  country,  and  more  completely  covering  the  whole 
sphere  of  medical  and  hygienic  work  for  this  purpose 
than  had  previously  been  envisaged.  Although  the 
country  at  that  time  might  be  said  to  be  already  under 
the  shadow  of  war,  these  documents  had  been  pre- 
viously prepared,  and  their  appearance  four  days  be- 
fore the  declaration  of  war  was  a  coincidence.  The 
chief  burden  of  the  additional  work  to  which  local 
authorities  were  urged  was  that  there  should  be  con- 
tinuity in  dealing  with  the  whole  period  from  before 
birth  until  the  time  when  the  child  is  entered  upon  a 
school  register;  and  the  memorandum  contemplated 
that  "  medical  advice  and,  where  necessary,  treatment 
should  be  continuously  and  systematically  available 
for  expectant  mothers  and  for  children  till  they  are 
entered  on  a  school  register,  and  that  arrangements 
should  be  made  for  home  visitation  throughout  this 


CHILD   WELFARE   WORK   IN   ENGLAND  265 

period."  It  was  added  that  "  the  work  of  home  visi- 
tation is  one  to  which  the  Board  attach  very  great  im- 
portance and  in  promoting  schemes  laid  down  in  the 
accompanying  memorandum  the  first  step  should  be 
the  appointment  of  an  adequate  staff  of  health 
visitors." 

The  main  provisions  of  this  memorandum  are 
printed  on  page  135. 

The  increase  of  work  since  that  date  may  be  gath- 
ered from  the  following  table,  which  shows  the  in- 
crease each  year  in  the  number  of  health  visitors,  of 
child  welfare  centres,  and  of  grants  given  on  the  50 
per  cent,  basis  by  the  Local  Government  Board  and 
the  Board  of  Education. 

Amounts  of  Grants  (pounds  sterling)  in  Each  Financial  Year 

to  Local  Authorities  and  Voluntary  Agencies,  on  the  Basis 

of  50  Per  Cent,  of  Total  Approved  Local  Expenditure 

Financial  Year  Local  Government  Board        Board  of  Education 

1914-15     ................       11,488  10,830 

6     ................      41,466  15,334 


I9I7-I8     ................    122,285  24,110 

1918-19  (estimated)    ----  209,000  44,000 

These  grants  do  not  cover  the  entire  scope  of  child 
welfare  work  carried  out  throughout  the  country,  and 
their  amount  must  not  be  taken  as  a  complete  indica- 
tion of  the  extent  of  this  work. 

The  increase  during  the  war  period  has  been  very 


266  CHILD  WELFARE  WORK   IN   ENGLAND 

great;  and  this  can  be  attributed  to  the  desire  to  do 
everything  practicable  for  mothers  and  children,  espe- 
cially those  belonging  to  soldiers  and  sailors  who  were 
risking  their  lives  for  the  country ;  and  to  the  increased 
realisation  of  the  importance  of  preserving  and  im- 
proving our  chief  national  asset  which  consists  in  a 
healthy  population.  During  this  period  there  was  a 
great  increase  in  the  industrial  employment  of  women, 
including  married  women,  in  factories  including  muni- 
tion and  other  works.  This  increase  it  is  believed 
amounted  to  a  million  and  a  half  workers. 

Notwithstanding  the  many  adverse  influences,  to 
which  must  be  added  great  overcrowding  in  many  in- 
dustrial areas,  especially  those  in  which  new  industries 
were  hurriedly  started,  and  the  increasing  cost  of  food 
and  especially  of  milk  with  a  scarcity  of  supply,  it  has 
been  seen  that  infant  mortality  remained  low  and  on 
the  whole  declined  during  the  whole  period  of  the  war. 

To  what  circumstances  can  this  be  ascribed  ? 

It  is  unnecessary  to  assume  that  this  result  was  en- 
tirely due  to  the  active  measures  favorable  to  mater- 
nity and  child  welfare  which  were  taken  as  an  unex- 
ampled scale,  though  these  measures  can  claim  an 
important  share  in  the  result. 

A  number  of  contributory  factors  were  at  work : 

I.  In  none  of  the  years  in  question  did  the  summer 
weather  favor  an  excess  of  diarrhceal  mortality.  With 
this  factor,  however,  eliminated  the  infant  mortality 
each  year  was  lower  than  in  previous  years. 


CHILD  WELFARE   WORK   IN   ENGLAND  267 

2.  Although  so  many  husbands  were  away  from 
home,  in  a  large  proportion  of  cases  the  wife,  in  virtue 
of  her  separation  allowance,  was  financially  in  a  more 
favorable  position  than  when  she  was  dependent  on 
her  husband's  wages  or  such  portion  of  it  as  he  ol- 
lowed  her  for  the  support  of  the  household. 

3.  In  addition,  every  soldier  became  an  insured  per- 
son, and  his  wife  was  therefore  entitled  to  the  Mater- 
nity Benefit  of  30  shillings  on  the  birth  of  a  child,  and 
an  additional  30  shillings  if  she  was  herself  an  em- 
ployed person. 

4.  There  can  be  no  reasonable  doubt  that  the  re- 
strictions on  the  consumption  of  alcoholic  drinks  and 
the  limitation  of  hours  for  opening  public  houses  were 
a  factor  in  improving  domestic  welfare. 

But  attaching  full  value  to  these  and  other  similar 
factors  which  undoubtedly  were  at  work,  chief  place 
must,  I  think,  be  given  to  the  awakening  of  the  public 
conscience  on  the  subject,  and  to  the  concentration  on 
the  mother  and  her  child  which  had  been  urged  in 
season  and  which  now  became  a  fact.  An  indication 
of  the  public  mind  is  given  by  the  advice  issued  by  the 
Local  Government  Board  in  August,  1918,  which  is 
quoted  on  page  248. 


INDEX 


Abbott,   J 

Abbott,  S.  W 

Alcoholic   drinks. . . .  123,    149, 

Anaesthetics    

Antenatal  work    

Bacteriological   diagnosis    .... 

Banks,  N.   P 

Biggs,   H 

Bowditch    

Budd,    Wm 

Burns,  John    

Burton,   R 


Care  Committees   

Causation     

Causation,    specific 

Cerebro-spinal  fever... 23,  76, 
Chadwick.  .2,  3,  n,  12,  25,  52, 

Chalmers    

Chapman    221, 

Character  and  health 

Childbearing,   care  of.  ...137, 

Child   mortality,   causes  of 

Child   welfare   work 

Cholera     

Colonies   for   consumptives. .  . 
Consumption,  see  Tuberculosis. 

Contacts    in   tuberculosis 

Creches    

Decadence    

Democracy  and   public   health 

Dental  assistance  

Destitution     (see     also     Poor 

Law)    31,  65, 

Deterrence,  principle   of   .... 

Diarrhoeal   diseases 20, 

Dirt  and  disease   . , 


187 

77 

261 

85 

2 

77 

2 

IS 
44 
71 

237 
147 

20 
126 

.  54 
70 
237 
173 
254 
248 
240 

12 
23S 

212 
263 

121 

47 
262 

87 

29 

241 

ii 


Dispensaries  for  tuberculosis.  216 

general  218 

Domiciliary   treatment    35 

Education  authorities  and  pub- 
lic health 56,  58,  86 

Educational    propaganda.  .130,  168 
"            work  of  -sanatoria  233 
Enteric  fever,  see  Typhoid 
Epidemiology,    present   limita- 
tions of 22,  8 1 

Eugenics   and  public  health. .  44 

Expectation  of  life... 20,   74,  192 

Factory    hygiene    and    legisla- 
tion      8,  26 

Farr,  Wm 2,  25 

Fulton,  J.   S 24 

Gerhard    15 

Goodnow     60,  63 

Grants  in  aid   56,   135,  265 

Historical  development  of  pub- 
lic health   42 

Holmes,   O.   Wendell    16 

Hospitals,      see      Institutional 

treatment 
as     housing     aux- 
iliaries, 

38,  77,   79,  98 
and   private   prac- 
tice      146 

Housing    38,  79 

"        and  tuberculosis  ....  203 

Huddersfield    246 

Ideals  of  public  work 4 

Ignorance  and  sickness   168 

Immunity  to  tuberculosis   ...  196 


268 


INDEX 


269 


Industrial  colonies 235 

Industry  and  public  health,  50,  161 

Infant  consultations   243 

Infant  mortality   144,  250 

Infant  mortality  and  poverty, 

153,  185 

Infants,  care  of 3° 

Influenza   23,  76,  127 

Inspectors  of  factories 51 

Institutional  treatment,  37,  79,     98 
Insurance  and  public  health, 

33.  59.  66,  88,  92,  95,  103 
Intemperance    149 

Jefferson,  President    6 

Jenner,  Wm 15 

Kay    2,     ii 

Koch,   Robert   192 

"       and   segregation   in  tu- 
berculosis   201 

Laissez  faire  policy 6 

Lay  workers,  utilisation  of  . .  3 

Loans  for  public  health  work.  14 
Local  Government  Board, 

S3,  58,  77 

Lowe,  Robert  28 

Mackenzie,    L 57 

Maclean,   D 31 

Malaria  147 

Malthus  6,  162 

Malthusian  hypothesis   164 

Massachusetts    2,     4 

Maternity  benefit,  34,  95,  in,  134 

Measles  20,  126 

Measurement     of     results     in 

life  saving 19 

Medical  benefit 34,  106,  no 

Medical    practice    and    public 

health 27,     83 

Medical  officers  of  health 63 

Midwives  Act 255 

Midwifery  nursing   260 


Milk  depots 243 

Mill,  James 6 

Ministry  of  Health   49 

Mother  and  child   132,  180 

Murchison,  Chas 15,     17 

National  Health  Insurance  Act, 

33,  59,  88,  104 
National  medical  service. ..  .32,  36 

New  England  i 

Notification  of  tuberculosis. . .   206 

"  of  births   245 

Nursing,  training  of  122 

"          public  health  work  of  126 

Oastler   177 

Overcrowding  7,  199 

Over-population    166 

Owen    177 

Panel  doctors   215 

Pasteur    21 

Percival    177 

Pettenkofer,  Voa 13 

Philanthropy  and  public  health, 

9,  37 

Physical    defects    81 

Pneumonia    76 

Poliomyelitis    23,  76 

Political  pull    102,  175 

Poor  law  and  public  health, 

27>  29,  31,  46,  49 

Population   problem    163 

Poverty,  causes  of  31,  182 

"         control  of   46,  1 14 

"         tests    139 

"         and  sickness, 

148,   162,   167,   184,  189 

Preventive  medicine   99 

Progress  of  public  health  ....  I 

Public  health  nurses  ....128,  154 

Racial   immunity   196 

Red  Cross  workers. .  127,  132,  143 
Registrar-General's  returns,  18,  25 
Relief  v.  prevention  ....  109,  190 


270 


INDEX 


Relief  v.  prevention   48 

Research   24,  35 

Resistance  v.  infection i95 

Respiratory  diseases 23,  125 

Rumsey     54 

Rural  conditions   161 

Sanatorium    benefit, 

34,  94,  in,  129,  214,  222 

Sanatorium   treatment    228 

Sanitation    and    infant    mor- 
tality     242 

Scarlet   fever    20 

Schools  for  mothers  244 

School  medical  inspection, 

3°,  57.  252 

Scope  of  public  health  work.  44 

Sedgwick    16 

Segregation  of  feeble-minded.  44 

"             in  tuberculosis. . .  200 

Sex  teaching 131 

Shaftesbury     177 

Shattuck,  L 2,  3 

Shop  hygiene   9 

Sickness  and  pauperism, 

Sickness  insurance   67,  116 

io,  32,  65,  87 

Sickness  registration 26 

Simon,  Jno., 

2,  4,  5,  9,  12,  13,  22,  25,  28,  55 

Smallpox    21 

Smith,  Adam    6 

Smith,   Southwood. .  .2,  9,   n,  12 

Smith,  Theobald 2 

Snow,  Jno 13 


Socialization    of    medicine, 

82,   102,  115 
State  treatment  of  disease, 

112,  137 

Statistical  studies,  influence  of  252 

Still-births    137 

Syphilis    i37 

Sykes,  J.   F.  J 244 

Town     living,     influence     on 

health    43 

Tuberculosis, 

20,  23,  34,  76,  78,  129,  193 
Tuberculosis  and  hospital  treat- 
ment      198 

"             and    overcrowding  199 

"             and   housing   ....  203 

"             notification  of  ...  206 

Typhoid   fever    15 

Typhus   fever    17,  20 

Unqualified  practice    31 

Urbanization    7,  1 59 

Venereal  diseases,  30,  8s,  131,  150 

Victoria,  Queen   10 

Vital  statistics,   importance  of    24 
Voluntary  agencies   141 

Walcott    2 

War 81,  120,  158,  179 

Water  supplies  and  health  ...  16 

Wells    159 

Whooping  cough   20 

Women,  work  of 122 

"         position  of    184 


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